
Book . n £ 



FACTS, OBSERVATIONS, 



AND 



PRACTICAL ILLUSTRATIONS, 

RELATIVE TO 

PUERPERAL FEVER, 

SCARLET FEVER, 

PULMONARY CONSUMPTION, 

AND 

MEASLES. 

A GENERAL VIEW OF THE 

PATHOLOGY AND TREATMENT OF 

CHRONIC DISEASES: 

WITH ILLUSTRATIONS OF THE UTILITY OF 

SULPHUREOUS WATERS, 

AND OBSERVATIONS ON THE EFFICACY OF 

THE BALSAM OF COPAIVA 

IN INFLAMMATIONS OF THE MUCOUS MEMBRANES, 



BY JOHN ARMSTRONG, M. D. 



Physician to the Fever Institution in London, 
Author of a Treatise on Typhus Fever, &c. 



THE END OF EVERY THING SHOULD DIRECT THE MEANS. 

William Penn. 



FIRST AMERICAN FROM THE SECOND LONDON EDITION. 

HARTFORD : 
OLIVER D. COOKE & SONS. 




1823, 




FACTS 



AND 



OBSERVATIONS, 



RELATIVE TO 



THE FEVER 



COMMONLY CALLED 



PUERPERAL 



BY JOHN ARMSTRONG, M. D. 

PHYSICIAN TO THE FEVER INSTITUTION OF LONDON, 



To communicate what I have tried, and leave the rest to 
others for farther enquiry, is all my design in puhlishing these 
papers. — Sir Isaac Newtorisjirst Advertisement to his Optics. 



FIRST AMERICAN FROM THE SECOND LONDON EDITION. 

HARTFORD: 
OLIVER D. COOKE & SONS. 

1823. 



TO 

JOHN RAMSAY, M. D. 

OF NEWCASTLE-UPON-TYNE, 



My Dear Sir, 

Allow me, thus publicly, to return you my 
thanks for the encouragement which you have 
given me in the prosecution of this little work, 
and the approbation you have expressed of the 
principles and practice that it contains ; and, 
having now brought it to a conclusion, I take the 
liberty of dedicating it to you, as a testimony of 
my high respect for your professional talents and 
private virtues. With the sincerest wishes for 
your happiness I am, dear Sir, 

Your obliged and faithful friend, 

JOHN ARMSTRONG. 

December 18. 1818. 




CONTENTS. 



PUERPERAL FEVER. 



Page 
Preface - - ' - - v. 

History of the Puerperal Fever 1 

Diagnosis ----=.--9 

Prognosis - - - '- - -'-16 

Prevention - - - - - 22 

Pathological Remarks - - - - 30 

Treatment - - - - - - 37 

The Character of the Stages considered in relation to the use 
of Bleeding, Purging, &c. - - - - - ib. 

Unsuccessful Cases - - - - - - 43 

Successful Cases - - - - - - 44 

Protracted Case of Catherine Bewick 47 

Case of Mrs. R. arrested speedily - - - - 54 

Cases of the Hospital Puerperal Fever 60 

Result of the Author's Experience in the Puerperal Fever in 
the Metropolis ------ 71 

Communicated Facts on the Hospital Puerperal Fever - 73 

Quotation from the MS. Lectures of Dr. William Hunter - ib. 
Remarks upon it - - - - - - 74 

Observations on Purgatives and Laxatives - - 78 

The Opinion of Erasistratus respecting the Changes which 

purgative Medicines induce in the Appearance of the Stools 81 
Hints on the Utility of attending to this Opinion in Practice ib. 
Remarks on the Utility of Opium in Inflammation of the Stom- 
ach, Bowels, &c. - - - - - 82 

Definition of the Puerperal Fever of Authors - - 87 

This Definition does not embrace all the Modifications of Fe- 
ver in the Child-bed State ib. 
General Remarks on Fever in the Child-bed State - - 88 
Description of a peculiar Congestive Disease of Child-bed, 

hitherto not noticed by Nosologists - - - ib. 

Its Pathology considered - - - - - ib. 

Its Treatment alluded to, and illustrated by what occurs after 
external Inquiries - - - - 90 



VI. CONTENTS. PUERPELAL FEVER. 

APPENDIX, No. I. Page 

Letter from J. T. Greg-son, Esq. Surgeon in Sunderland, ad- 
dressed to the Author, containing two Cases of the Puer- 
peral Fever, and some observations on that Disease - 95 

Letter on the same subject, addressed to the Author, by R. 
Gregory, Esq. Surgeon in Monk- Wearmouth - - 102 

Letter addressed to the Author, by J. Wolfe, Esq. Surgeon in 
Chester-le-street, near Durham - - - 104 

Observations on the State of the Atmosphere between January 
and October, 1813, the Term in which the Puerperal Fe- 
ver was most Prevalent - - - - - 106 

APPENDIX, No. II. 

Letter from Dr. Joseph Clarke, to the Author, containing Re- 
marks on some Parts of the First Edition of this Work - 109 

An Abstract of the Registry kept at the Lying-in Hospital in 
Dublin, from the 8th day of December, 1757, (the day it 
was first opened) to the 3 1 st day of December, 1816 - 112 

Letter respecting Puerperal Fever from Thomas Aicock, Esq. 
Member of the Royal College of Surgeons, and Accoucheur 
to St. James' Infirmary - - - - 115 




PREFACE. 



THE former edition of this treatise was offered to the 
medical public as the first of an intended series of practical 
illustrations of febrile diseases, drawn from clinical facts 
and anatomical investigations. Since then the promise has 
been partly redeemed by the publication of two volumes, 
in which an endeavour was made to describe and explain 
the effects of simple excitement, inflammation, and conges- 
tion on the various functions and tissues of the body ; but 
as, in the mean time, the puerperal fever has been repeat- 
edly brought under my review, it became necessary, that 
the particulars latterly acquired should be embodied with 
those formerly published, in order to fix the work on a 
broader and more substantial basis. 

The exercise of common sense on the objects of percep- 
tion, and what is called the inductive philosophy, seem to 
be very nearly the same thing; for plain unbiassed men ? 
in all practical arts, naturally advance frtfm facts to infer- 
ences, the method here pursued. If this dissertation 
should prove the mean of lessening the ravages of the pu- 
erperal fever, its utility must be attributed to the advantages 
which I have derived from the labours of my predecessors, 
to the progressive state of medical science, and particular- 
ly to the cases which have been presented in the course of 
my practice. The principal lights, if such they may be 
deemed, have been thus conveyed to me, and I can merely 
claim the office of reflecting them upon the important sub- 
ject which occupies the following pages. 

23, Southampton Row, Russell Square, Januaiy 1, 1819- 



£■ h> '.' 






FACTS AND OBSERVATIONS 



RELATIVE TO 



THE FEVER COMMONLY CALLED 
PUERPERAL. 



GREAT discrepancy of opinion still exists among writers 
of celebrity, respecting the nature and treatment of the 
fever usually denominated puerperal. It was the convic- 
tion, that this difference had given rise to much doubt and 
indecision, on points of vital importance, which induced me, 
towards the close of the year 1813, to illustrate something 
like general principles to guide the practitioner at the bed- 
side ; and as attentive observation since that period has on- 
ly tended to strengthen my confidence in those principles, 
I am induced, in this revised edition, to attempt their mor^ 
complete establishment, by an ampler detail of facts, re- 
specting this disease under its epidemic and sporadic forms. 
The puerperal fever prevailed epidemically in the coun- 
ties of Durham and Northumberland, in the year 1813, and 
among other places, at Sunderland, where I then resided. 
This complaint, as it was presented to me, generally occur- 
red about twenty-four or thirty hours, and seldom later than 
four days, after delivery. It did not seem to depend upon 
difficulty of labour; for in most of the women in whom it 
occurred, parturition was remarkably easy, and the placen- 
ta was separated after a proper interval, and without more 
than usual pain. Nor was the lochial discharge, before the 
attack, in any way apparently affected. The disease was 
mostly ushered in by very slight shiverings, or rigors, by 

2 



4 THE PUERPERAL FEVER. 

chilliness. The cheeks were alternately flushed and dead- 
ly pale, the eyes lost their lustre, the pupils were much di- 
lated, and a kind of dewy perspiration stood upon the face 
and forehead. The pain gradually and entirely receded 
from the abdomen, which became much more distended, 
and it usually happened that dark, slimy, and very fetid 
stools were discharged from that time onward. The thirst 
was unceasing; and when any liquid was offered, the pa- 
tients hastily seized the vessel, and glutted down its con- 
tents, as if they had previously been expiring for want of 
drink. The tongue for the most part was brown, or rather 
black and parched, and had aphthse upon it, which even ap- 
peared about the edges of it at an early period. In one 
very bad case, however, the tongue continued clean and 
moist to the last ; but there was an almost perpetual vomiting 
throughout the second stage, though only a slight nausea oc- 
curred in the beginning, and very little vomiting in the rest 
of the first stage. Indeed vomiting was always more urgent 
in the last than in the first stage of the disease, and the mat- 
ter then thrown up very much resembled coffee-grounds, and 
was offensive to the smell.* The teeth and gums were 
crusted with dark, slimy sordes, and the breath was dis- 
agreeable, as if it had been tainted with mercury. Through- 
out the complaint there was a short teasing cough, but this 
was more especially the case in the last stage, when the 
respiration grew very short, feeble, and frequent, and the 
alas nasi were thrown into perpetual motion. 

Soon after the advancement of the second stage, the 
patients began to talk incoherently, they frequently made 
attempts to get out of bed, and occasionally, after having 
lain still a short time, suddenly started, and spread out their 
hands, which were then very tremulous, as if to ward some- 
thing off that was approaching them. About this time, two 
patients became gradually collected, complained of no pain 
whatever, looked and spoke cheerfully, and flattered them- 
selves that they should soon be well : this illusion contin- 
ued till within an hour or two of their death, rendering them 
completely insensible to their real situation ; and even to 
friends, though warned by the medical attendant, their death 

• Compare this with that appearance of the stools which Mr. Wolfe, Sur- 
geon, of Chester-le-Strect, considers in another part of this work as one 
of the diagnostics of the disease 



THE PUERPERAL FEVER. 5 

was at last unexpectedly sudden. .But in three other unfa- 
vorable cases, the light wanderings of the mind which took 
place at an early period of the second stage, were not suc- 
ceeded by a state of serenity, but by a low muttering de- 
lirium, speedily followed by a stupor, in which the patients 
lay with their eyes half-closed, and could not be roused 
from it, but by loud speaking, upon which they started as 
from a disturbed sleep, uttered some vague and hasty ex- 
pressions, and then sank into the same condition as before. 
A few hours before death, in these cases, some dark scat- 
tered petechiae appeared, and the skin was in that peculiar 
state which accompanies the last stages of tetanus, and the 
brain fever of intoxication,* the whole surface felt soft, 
relaxed, and clammy, and the hand glided almost as smoothly 
over it as if wet by soap and water. In the above three 
instances, also slight stertorous breathing occurred near the 
termination of the disease, and, last of all, general though 
not violent convulsions. 

This complaint, when not arrested, generally ran its 
course in a few days. Soon after death, the bodies became 
rather livid and very offensive to the smell, and the abdo- 
men immensely distended. It is to be regretted that no 
examination could be obtained, as morbid dissection might 
perhaps have thrown some additional light on the nature of 
the disease. In the course of practice, when apprehend- 
ing that advantage might be derived from anatomical in- 
vestigation, I have frequently had to lament that it could 
not be obtained, especially in cases fatal during child-bed. 
Though one cannot but respect those feelings which vene- 
rate the dead, yet it would be well for society, if the con- 
sideration of the general good were permitted to operate so 
as to overcome, on such occasions, the private sympathies 
of our nature. And this is the more to be desired, for till 
it can be accomplished, medical science must necessarily 
be retarded upon those very points respecting which it is 
most needful that it should rapidly advance. But to return 
from this digression, which the importance of the subject has 
led me to make : 

At Sunderland the first case of the puerperal fever hap- 

* The disease which, in my work on typhus, is called a peculiar disorder 
of drunkards, and which Dr. Sutton has denominated Delirium Tremens, in 
his valuable publication. See the Edinburgh Medical Journal, for July, 
1813. 



6 THE PUERPERAL PEVERe 

pened in January, 1313, but apparently under a sporadic 
form; and the few cases which appeared throughout the 
. winter assumed the same character, the majority being so 
mild as to yield to brisk purging and a,spare regimen. In the 
spring of the year, however, the disease;became much more 
formidable in its character, and about this period, five pa- 
tients fell victims to its violence in rapid succession. In all, 
forty-three cases occurred from the 1st of January to the 
1st of October, when the disease ceased ; and of this num- 
ber, forty were witnessed by Mr. Gregson and his assistant 
Mr. Gregory, the remainder having been separately seen 
by three accoucheurs. It may seem, and actually is re- 
markable, that so large a proportion of the cases should 
have occurred in the practice of two gentlemen, but in this 
respect they were by no means singular. At Chester-le- 
street, about nine miles distant from Sunderland, several 
cases occurred to Mr. Wolfe, while Mr, Nelson, junior, of 
the same place, only met with a solitary instance now and 
then. Dr. Ramsay told me, that one accoucheur lost seven 
patients in a town not far distant from Newcastle-upon- 
Tyne ; and Mr. Fife stated; that the disease was confined 
to the patients of that practitioner, and in the preceding 
year, in like manner, to those of one midwife in Newcastle 
itself. In the beginning of May, 1813, it appeared in the 
neighbourhood of Alnwick, ttnd prevailed for some time af- 
terwards ; but in that town it was limited to the practice of 
two gentlemen, Mr. Wilson and Mr. Stephenson, though one 
midwife, who had a considerable increase of business, had 
not a case of the disease. Another midwife, however, who 
had been about two days in the house of a lady dying of the 
puerperal fever, went into a district about eight miles dis- 
tant from Alnwick, and there delivered several women, 
nearly the whole of whom were attacked with the puer- 
peral fever. My friend Dr. Ayre of Hull, too, informed 
me that the disease had been confined to the practice of 
tw r o accoucheurs at different places in Yorkshire ; and I 
could accumulate evidence to show, that this w r as further 
the case in other quarters of the county of Durham, and 
even much more to the northward. In this particular, 
therefore, the epidemic strikingly coincided with that no- 
ticed by Dr. Gordon many years ago in Aberdeenshire: 
for be hasdrstincfly mentioned, that the disease occurred to 



THE PUERPERAL FEVER. 7 

certain individuals, while it was entirely unknown in the 
practice of others living in the same neighbourhood ; and 
he naturally enough attempts to account for a circumstance 
so singular by supposing, that the practitioners conveyed 
the contagion from patient to patient, 

From all the circumstances which I have been able to 
collect, it appears, that the puerperal fever, above descri- 
bed, existed in fact for more than two years in different 
parts of the counties of Durham and Northumberland. In 
the year 1811, it arose in the neighbourhood of Stockton- 
upon-Tees, afterwards in the town of Newcastle-upon- 
Tyne, in Sunderland, near Chester-le-street, then in the 
vicinity of Newcastle-upon-Tyne, and, lastly, in and about 
Alnwick. In its course it assumed two principal varieties, 
one accompanied with the symptoms of simple peritonitis, 
and the other, thoqgh marked by a less evidently declared 
inflammation of the abdomen, was connected with a more 
overpowering and oppressive fever from the commence- 
ment. Those who have cautiously noticed the various 
characters which abdominal inflammations assume, will be 
easily able to comprehend how the type of the fever may 
be modified by the seat and extent of the inflammation •, and 
what seems actual debility in the beginning of such affec- 
tions, is only a greater degree of general oppression from a 
more intense inflammation, how much soever that inflam- 
mation may be marked by the change which has taken 
place in the nervous system. In both the forementioned 
varieties, the puerperal fever had the same general charac- 
ters in the last stage; but the first variety was less rapid 
than the second, though both went on to a fatal termina- 
tion, unless active remedies were promptly applied at an 
early period. During its prevalence, a great many women 
died of this disease ; and this was so much the case in some 
parts of Northumberland, that I was credibly informed, 
every patient perished, who was not bled in the beginning. 
In a few cases, and only in a few, the puerperal fever had 
a more protracted course, and a more obscure character, 
answering exactly to the description of some which Dr. 
Ramsbotham of London had previously met with, and 
which he mentioned to me in an excellent letter, respect- 
ing the nature and treatment of this complaint. In these 
cases the pulse at the commencement ranged from about 



8 THE PUERPERAL FEVER. 

100 to 120 in the minute; there was at first little affection 
of the tongue, little affection of the belly, and that only 
complained of when the hand was pressed forcibly upon 
the abdomen for some time. The mind was perfectly col- 
lected, and the countenance for some days not altered ; 
but the patients were liable to feel some uneasiness in the 
head, and especially about the orbits of the eyes. The 
symptoms insidiously advanced, the pulse acquired a great- 
er velocity, the pain of the belly increased, and after a few 
days' continuance of abdominal tension, the countenance 
began to change, and the mind to wander. Dr. Ramsbo- 
tham justly remarks, that this form of the disease is often 
considerably advanced before it can be satisfactorily de- 
tected 5 and he (Considers it the more dangerous on this ac- 
count, and because prompt and powerful means, from the 
apparent mildness of the symptoms, do not appear to be 
so early demanded. 

Puerperal fever is mostly divided into epidemic and spo- 
radic, and in both the abdominal affection has been consi- 
dered the essential part. It shall afterwards be shown, 
that this arrangement is not sufficiently comprehensive, 
though in these pages, increased heat and abdominal in- 
flammation are regarded as pathognomonic signs of what 
authors mean by the puerperal fever; and from what has 
been said, it will be evident, that in the most rapid cases 
this inflammation is acute, and sub-acute in the more pro- 
tracted. Yet it has appeared to me, that the causes of 
what is called the puerperal fever are more varied than 
most authors allow ; and the effect resulting from these 
causes is the same, on account of the previous and pecu- 
liar state of the abdomen, whether the disease be sporadic 
or epidemic. Notwithstanding the many discoveries in 
chemistry, we are yet unacquainted with those properties 
of the atmosphere, which are supposed to have an agency 
in the production of contagious and epidemic diseases. 
But that this matter may still be open to investigation, I 
have given some account in the Appendix of the states of 
the atmosphere while the epidemic above described was 
most predominant, and also of those diseases which appear- 
ed at the same time. 

The succeeding observations will be of a more desulto- 
ry and general nature, and though intended to include most 



THE PUERPERAL FEVER. 9 

particulars of importance relative to the diagnosis, progno- 
sis, and prevention, they are especially designed to exhibit 
the method of treatment which has been so successfully 
employed in this disease in private practice; and at the 
close of the work some cases will be given to demonstrate, 
that the same method is applicable to what has been deno- 
minated the hospital puerperal fever. 



DIAGNOSIS. 



IF in a therapeutic view, as shall be afterwards shown, 
the puerperal epidemic should be thought essentially differ- 
ent from the ordinary peritonitis of lying-in women, the 
distinction will, most assuredly, be made at the hazard of 
life. The admirers of nosological minuteness, however, 
may contend that there are circumstances in the rise, pro- 
gress, and sequel of the epidemic, which sufficiently mark 
it from the more simple peritonitis ; but I can assert, with 
some degree of confidence, that if these circumstances be 
allowed to influence the practice very materially, they will 
be found exceedingly fallacious at the bed-side, however 
plausible they may seem in books. These, then, being the 
firm convictions of my mind, puerperal fever shall only be 
particularly distinguished from milk-fever, after-pains, in- 
flammation of the uterus, and that ephemera called the 
weed, to which child-bed women are very liable. 

The milk-fever is known, principally, by throbbing, irri- 
tation, and enlargement of the breasts, and by the pain be- 
ing confined to the mammae, during the continuance of the 
febrile symptoms ; whereas in the puerperal fever, the pain 
begins and continues in the abdomen, while the breasts, for 
the most part, are neither distended nor uneasy, but com- 
monly more flaccid than natural. Besides, there is consi- 
derably more lassitude and weariness, a more urgent nau- 
sea or sickness, and a quicker pulse in the commencement 
of the puerperal than of the milk-fever. 

In after-pains, at certain times, pressure can be borne 
without uneasiness, but in the puerperal fever the belly is 

3 



10 THE PUERPERAL FEVER. 

sore to the touch, and pressure always aggravates the pain. 
In the first, there is no accession of fever, nor an accelerated 
pulse, the pains are grinding like those of labour, and, like 
them, they are succeeded by intervals of complete ease; — 
on the contrary, in the last, there is an accession of fever 
marked by an uncommon rapidity of the pulse, and the pairi 
is without intermission. 

Simple hysteritis may be known by a burning, throbbing 
pain, fulness, and oppressive weight in the region of the 
uterus, by frequent calls to make water, which is passed 
with great pain and difficulty, by the uterus itself feeling 
hard, hot,* and enlarged, and being exquisitely sensible 
when pressed upon, by violent pains darting through to the 
back, and down to the groin and thighs, by an increase of 
pain from raising the trunk erect, and by the soreness and 
fulness being more confined to the lower part of the abdo- 
men throughout the attack than in the puerperal fever. 
When the above symptoms occur with increased heat, 
thirst, quick pulse, sickness of the stomach, and suppression 
of the lochia, there can be no question as to the seat of the 
disorder. Nevertheless, however plain these distinctions 
may appear upon paper, or in lectures, it is certain from 
dissections, that hysteritis often, very often constitutes a 
part of the abdominal inflammation attendant upon puer- 
peral fever.t Nor will this seem at all surprising, when 
we reflect that the uterus, after the separation of the pla- 
centa, is in fact a kind of recently wounded member, to 
which inflammation may be readily imparted, especially if 
the lochial discharge, as frequently happens in the puerpe- 
ral fever, be diminished or suppressed. When simple hys- 
teritis does take place, Denman judiciously observes, that 

* The heat, I believe, is always sensibly increased to the touch in an in- 
flammation of the uterus ; and in some instances I have found it very pun- 
irent This increase of heat indeed has not escaped the observation of 
Lommius : — 

Porro si uteri cervix inflammationem sustinet, id quod frequentius fieri 
dixi, abdomen dolet, ipsumque uteri os admoto digito durum occurrit, 
fervidum, atquc praeclusum. Medicin. Observ. lib. ii. p. 235. 

t When the uterus becomes inflamed, it takes place almost always un- 
der the same circumstances, viz. very soon after parturition. The inflam- 
mation is sometimes confined to the* uterus itself, or its appendages, but 
the peritonaeum in the neighbourhood is most commonly affected, and fre- 
quently over its whole extent. Baillie's Morbid Anatomy, p. 362. 



THE PUERPERAL FEVER. n 

/ 

it is much less dangerous, particularly after parturition, 
than an equal extent of inflammation in any other of the 
abdominal viscera, because the uterus, as a kind of outlet? 
admits of a return of the lochial discharge, which may les- 
sen, and even remove the disease. The last mentioned 
author too remarks, that not one instance has been obser- 
ved of any woman, who had an abscess in the breast, being 
attacked with the puerperal fever ; nor any who, in conse- 
quence of their labour, had such an affection of the blad- 
der, as to occasion a suppression of urine. * My own ex- 
perience tends to confirm the first, and to refute the last of 
these remarks ; for I have never known a case of this dis- 
ease to occur where the breast suppurated, but I met with 
one which took place under a suppression of urine, though 
the circumstance is probably rare. 

The ephemera called the weed is ushered in by strong 
rigors, which, commonly in less than an hour, are followed 
by heat, thirst, and general excitement, the whole train of 
symptoms being terminated in twenty-four or thirty hours 
by profuse perspiration. The absence of abdominal irri- 
tation is generally sufficient to prevent the possibility of 
mistaking this disease for the puerperal fever. 

Severe griping pains, occurring in the child-bed state, 
with fever and tenesmus, have been considered by some as 
the characteristics of enteritis, but I cannot help suspecting 
that these nice discriminations are more specious than use- 
ful. 

Having thus endeavoured to distinguish puerperal fever 
from milk-fever, after-pains, hysteritis, and the ephemera, 
I shall now be more at liberty to pursue the consideration 
of the disease itself, and may, perhaps, hope that the inex- 
perienced student will be prevented from confounding it 
with the forementioned complaints. 

The puerperal fever, especially under an epidemic cha- 
racter, sometimes creeps on in a very insidious manner, 
the abdominal inflammation being masked by an oppressive 
languor, and a diminished sensibility of the nervous sys- 
tem ; yet, in such cases, the disease may generally be de- 
tected by the great frequency of the pulse, by the quick- 
ened respiration, by flatulence of the stomach, and by the 

* See an Introduction to the Practice of Midwifery, by Thomas Don- 
man, M. D. Fourth edition. London, 1805. Vol. ii. p. 477, 478. 



12 THE PUERPERAL FEVER. 

patients shrinking when pressure is applied over the ahdu 
men, though they previously made little or no complaint of 
pain in that part. In those cases of the puerperal fever 
which commence with uneasiness in the head, the patients 
sometimes complain of little or no painjn the belly for two 
or three days after the first attack ; but the breathing is al- 
ways quicker, the pulse more frequent, the abdomen round- 
er and fuller, and the stomach more flatulent than natural. 
Forcible pressure on the belly is one of the best tests of 
the abdominal inflammation ; and when it is made, the 
practitioner should always watch the countenance of the 
patient, for that will undergo an immediate change if the 
pressure give uneasiness ; an uneasiness which some pa- 
tients strive to conceal when they are aware that evacu- 
ant measures would follow its acknowledged existence. 
But even if pressure on the belly should induce no change 
of the countenance, still if the pulse should be rapid, and 
the respiration anxious, it is safest ta treat the case as if 
abdominal inflammation openly existed ; for I have known 
some instances where this treatment was omitted, and dis- 
section after death discovered traces of inflammation both 
in the brain and abdomen. Sometimes in the puerperal 
fever, as in typhus, there is an universal soreness of the 
flesh, a condition of the surface which may be extremely 
embarrassing ; for if the practitioner should at first press 
his hand over the abdomen, the patient would shrink much 
— but if he tried pressure in other parts, she would stiil do 
the game, so as to leave doubts as to the presence of vis- 
ceral inflammation. In such cases, however, the brain 
and spinal cord are commonly more or less inflamed, of 
which the soreness of the surface is symptomatic ; but ii 
the patient lie upon her back with the feet drawn upwards, 
and if stretching them suddenly downwards give pain, and 
if the breathing be hurried, and the stomach flatulent and 
irritable, abdominal inflammation may be presumed also 
to exist. Thus it will appear, that two opposite states 
of the nervous system may occur in the puerperal fever, 
one in which the sensibility is diminished, and another in 
which it is increased ; and without due care on the part of 
the medical examiner, both may contribute to mislead him 
as to the actual state of the abdominal viscera. 

My friend, Mr. Wolfe of Chester-lc-Street, who has 



THE PUERPERAL FEVER. (3 

p aid great attention to the puerperal fever, considers the 
appearance of the alvine evacuations as one of the best di- 
agnostics. Whenever, therefore, febrile symptoms take 
place, with pain and soreness of the abdomen, after partu- 
rition, he immediately gives the patient a brisk purge ; and 
if, when the contents of the lower part of the bowels have 
been dislodged, the stools should be of a dark colour, 
somewhat resembling coffee-grounds, very copious, of the 
consistence of thick gruel, and of a fetid smell, he is then 
confirmed in his opinion, that he has to encounter an af- 
fection requiring more than ordinary activity of treatment, 
and subsequent events have always fulfilled his predic- 
tions.* 

As an additional proof of the justness of the above re- 
marks, I have, on inspecting the evacuations, generally 
found them dark, slimy, fetid, and unexpectedly large. 
Indeed, excepting that they are commonly mixed with 
hard pieces of scybala, they have neither the ordinary 
smell, consistence, nor colour of natural fecal stools ; but 
seem to be composed, for the most part, of some excre- 
mentitious matter, somewhat like thin, dirty yellow paint, 
thrown out in considerable quantity in the course of the 
disease.! It seems to me highly probable, that, in many ca- 
ses of the puerperal fever, the villous coat of the bowels 
as w r ell as the liver are affected : in some instances, that 
affection may consist in a mere change of secretion, but 
in others it appears to amount to inflammation ; and in one 
example this had clearly occurred, for after death the li- 
ning of the intestines and liver exhibited the marks of hav- 
ing been inflamed. The mucus membranes are very lia- 
ble to inflammation in many fevers, and they have a sort 
of continuous sympathy, as Bichat observes, by which they 
reciprocally affect each other: but as inflammation of their 
surfaces is often attended with but little uneasiness, it is 
too frequently overlooked ; and in this way the increased 
secretion from the inflamed lining of the bowxls is frequent- 
ly mistaken for simple diarrhoea in acute fevers. 

In many instances, it is remarkable how very indifferent 

♦Consult Mr. Wolfe's communication in the Appendix. 

t Quae excernuntur nigra sunt, et interdum perquam mali odoris.. Hip.= 
pocrates ; as translated by Hulme, in bis Treatise on Puerperal Fex?r. 



1 4 THE PUERPERAL FEVER. 

patients are to surrounding objects, and this indifference 
is of such a nature, as not only to extend to objects in ge- 
neral, but to render them inattentive even to the suckling 
of their infants. This last mentioned circumstance has 
been imputed by some to the suppression of the lacteal se- 
cretions, but this is certainly not the cause, since I have 
seen it in the very commencement of some cases, in which 
the secretion of the milk was but little affected. What- 
ever may be the cause of this curious phenomenon, it in- 
dicates an extraordinary powe» of disease, which can in a 
few hours paralyse the maternal affections. In many ca- 
ses, if the apartment be ever so well cleaned and ventila- 
ted, and the linen daily changed, there is still an offensive 
smell about the bed of the patient ; and in the first stage, 
particularly of the more severe cases, a peculiarly striking 
expression of the face, which I have not seen in any other 
complaint. The countenance manifests alarm and solici- 
tude, as if the person affected was the subject of two differ- 
ent emotions at the same time ; at least I am not able to 
convey a more definite conception of the physiognomy 
soon after the attack of the disease. 

In touching upon the diagnosis, it may not be irrelevent 
to remark, that in the epidemic which has been delineated, 
the state of the lochia was various. In by far the greater 
number of cases which took place at Sunderland, they 
were gradually diminished or suppressed after the full de- 
velopement of the fever; but in those cases w r hich occur- 
red to Mr. Wilson, of Alnwick, the lochia were at no period 
cither diminished or suppressed, while in the examples which 
Mr. Stephenson, of the same place, encountered, they 
were mostly diminished or suppressed. Again, in the pa- 
tients which Mr. Wolfe of Chester-le-Street attended, this 
discharge was sometimes obstructed, and at other times not 
deficient in quantity ; and were it necessary I could quote 
some of the best authors to prove, that the lochia are af- 
fected in some cases, but not in others. Yet so far as my 
inquiries have gone, and they have been extensive among 
observant practitioners, I should be authorized to state, 
that the lochia are most frequently diminished or suppressed 
in the progress of the puerperal fever; but whenever this 
happens, their diminution or suppression can be clearly 
traced as an effect, and therefore ought never to be con- 



THE PUERPERAL FEVER. 15 

founded as a cause of the disease. For my own part, and 
I have been consulted in a great variety of puerperal cases 
of one kind or other, 1 have never been able distinctly to 
trace the origin of any febrile disease, to the diminution or 
suppression of the lochia, which have always appeared to 
me as the mere consequences, not as the occasions of fever 5 
though some insist on a contrary view of the subject. 

From separate copies of his lectures, it appears, that Dr. 
Hamilton, junior, the distinguished professor of midwifery 
in Edinburgh, maintains that the lochia! discharge is not 
suppressed in cases of the true puerperal fever ; and partly 
upon this assumption, he attempts to distinguish it from 
other affections of child-bed, which resemble it most. But 
I have showjn, in the puerperal fever which prevailed epi- 
demically in the north of England, that the lochia were 
sometimes suppressed, and sometimes not at all deficient; 
and the same was the case in the diseases which Dr. Gor- 
don and Air. Hey have described, not to mention other in- 
stancesmvhich might be adduced to prove the variable state 
of this discharge in the puerperal fever. The distinction, 
therefore, which Dr. Hamilton has endeavoured to establish 
must fall to the ground, since, so far from being supported, 
it is directly opposed by a host of facts. From these re- 
marks it will not be presumed, that I mean to arraign this 
deservedly eminent individual for the open expression of 
his opinion ; but being confident, that this opinion is alike 
fallacious and dangerous, I feel it my duty to protest against 
it, as the high authority whence it proceeds may have 
powerful influence over those ignorant of the subject. 
Even the late ingenious Dr. John Clarke, anxious as he wa6 
to draw a line of demarcation between puerperal peritoni- 
tis, and what he called the low child-bed fever, completely 
failed in the attempt ; for no unprejudiced man can read 
his descriptions without inferring, that the latter was an 
aggravated degree of the former, which the appearances 
after death, detailed by this author, render almost indispu- 
table. Yet this classification, however defective, was an 
approach towards the truth, and has powerfully assisted the 
pathological researches of those who rather regard facts 
than speculative opinions. 

But, to prosecute the diagnosis — abdominal pain, or sore- 
ness, quick anxious breathing, unusual frequency of the 



16 THE PUERPERAL FEVER. 

pulse, increased temperature, anorexia, prostration of the 
vital and voluntary powers, with an unnatural condition of 
the excrements, are among the chief pathognomonic signs 
of the puerperal fever ; but in some cases of an acute 
kind, especially where the head is affected, the abdominal 
disorder may be indistinctly declared for some time, and 
therefore all the collateral circumstances of the case should 
be taken into the account, in forming the diagnosis. As 
for that modification of the puerperal fever, which is at- 
tended with an obscure, or rather with a sub-acute species 
of abdominal inflammation, it may be best recognized by 
quickness of the pulse, anxiety of the respiration, fulness 
and roundness of the abdomen, flatulence of the stomach, 
and uneasiness of the belly on forcible pressure, with an 
evident change induced in the countenance at the same 
time. Besides, the patient generally lies, as if by instinct, 
upon her back, with her knees elevated ; a position which 
both relaxes the abdominal muscles, and keeps the bed- 
clothes from pressing upon the surface of the beMy ; and 
even in such instances, as before intimated, if the patient 
be directed to stretch her legs suddenly, and fully down, 
some uneasiness will be occasioned in the belly, and there- 
by some alteration fn the expression of the face, from the 
tension which this change of position produces in the ab- 
dominal muscles. In concluding this topic, I beg leave most 
earnestly to advise practitioners of midwifery to visit their 
patients very frequently, for several days after delivery, 
and narrowly to observe the state of the pulse, tongue, 
stomach, bowels, respiration, countenance, and skin : for 
such attentions will generally enable them to perceive the 
most insidious approaches of the puerperal fever; and it 
ought never to be forgotten, that it is in the provident an- 
ticipation of disease, the medical man most strikingly shows 
the force of his understanding, and the efficacy of his art. 



PROGNOSIS. 



FROM the days of Hippocrates* to the present time, 
the puerperal fever has been esteemed imminently danger- 

* Si mulieri pregnanti fiat in utero erysipelas, lethale est. 

Hippocrates 



THE PUERPERAL FEVER. r, 

uus ; indeed, some writers have not hesitated to place it 
next to the plague in the catalogue of diseases. Though 
I perfectly agree with the common opinion, as to its dan- 
ger, and am convinced that part of its fatality may be fairly 
ascribed to its natural tendency, yet I am fully persuaded 
that it may generally be arrested in the beginning, and 
that much of its fatality has been occasioned by our great 
caution, timidity, and indecision in treating it. In truth, it 
is an extraordinary malady, and requires extraordinary 
remedies, rapid ,as well as powerful in their effect ; for, in 
the most severe examples, if the first twenty hours from its 
marked appearance be lost in doubt and hesitation, no 
human efforts, generally speaking, can afterwards atone 
for the error. On the contrary, if these golden moments 
be seized without delay, and an active treatment steadily 
pursued, it is my firm belief, that there are few febrile dis- 
orders of the more serious kind, which afford the physician 
a fairer chance for the successful exercise of his functions, 

Notwithstanding, it would only be proper that the phy- 
sician should always give a guarded prognosis in this dis- 
ease, and more especially when it is epidemical ; since it 
has happened in this, as in every other epidemical fever, 
that cases have proved fatal, in defiance of the most prompt 
a nd judicious measures. 

Dr. Foster has obseved, that there is often a treacher- 
ous remission about twenty four hours after the attack, and- 
this also, is often the case about the end of the third 
day. Whenever, indeed, any remission of pain takes place, 
the professional attendant must neither be betrayed into a 
sanguine declaration of a speedy recovery, nor into a su- 
pineness of practice ; because under such an apparent 
abatement, the disease sometimes secretly and rapidly ad- 
vances, and even when that is not the case, it sometimes 
returns with greater violence than before. 

It has been stated, by some authors, that the pain in 
general suddenly leaves the belly before puerperal fever 
ends unfavourably. But, from an almost hourly attendance 
upon many cases. I am inclined to believe that their asser- 
tions on this point have been too hastily made, and that the 
pain, in the majority of examples, gradually abates, and, in 
some, even continues distressing to the last. Occasional- 
ly, however, there can be no doubt but that there is a stir- 

4 



18 . THE PUERPERAL FEVER. 

prisingly sudden transition from the greatest suffering to the 
most perfect ease ; and when this happens with a cold, 
clammy skin, and a rapid, small, fluttering pulse,, it must be 
looked upon as a fetal sign — as the last illumination of life. 
It seems agreed by ail accurate observers, that the ear- 
lier the attack the greater is the danger, and that those 
whose powers of feeling are much diminished from the be- 
ginning, and who consequently complain but little, generally 
sink under the pressure of the disease. On the other 
hand, an excess of sensibility is always to be dreaded, for 
I have had opportunities of remarking, that those patients 
seldom recover who are tremblingly alive to every surround- 
ing impression.* It is well known that unmarried women 
do not recover so well as married ones, the mental irrita- 
tion necessarily attendant upon their situation considerably 
increasing the febrile excitement, rendering them extreme- 
ly restless, and thus augmenting the danger. 

The slightest approach to mental confusion or delirium 
is an inauspicious sign, at any period of the complaint. An 
agitated countenance, with a hurried, unconnected manner 
of speaking, constant sighing attended with a tossing of the 
arms, pain and oppression of the chest, visual deceptions, 
imaginary strange sounds and voices, muttering and stupor, 
are among the most unfavourable symptoms. Dr. Foster, 
on examining the bodies of two women, who apparently 
died of the puerperal fever, discovered that the omentum 
in both was lacerated near the middle, almost entirely 
across from side to side.t It is, however, readily acknow- 
ledged, that such lesions are exceedingly uncommon, yet 
when they do happen, as they place the patient beyond the 
power of art, and as nothing but actual dissection can 
prove that they do not exist in any case, we should, in every 
instance, be the more cautious in passing a prognosis. 

+ Women of delicate constitutions, very susceptible, and continually 
agitated by hopes and fear, are, of all others, the most subject to it, and 
recover with the greatest difficulty. Practical Observations on the Child- 
bed Fever, &c. by John Leake, M. D. Fifth edition. Vol ii. p. 43. 

tThe Principles and Practice of Midwifery. By Edward Foster, M. 
D. late Teacher of Midwifery in the City of Dublin. Edited by James 
Simms, M. D. 1781. Consult p. 297* 



THE PUERPERAL FEVER. is 

irreparable derangements in the structure and functions 
of the abdominal viscera are often made in the eo m;e of 
twenty-four hours :* the time, therefore, which the disease 
has continued, ought materially to influence the opinion to 
be delivered. In one robustly-formed young woman, 
whom I was called to visit about three years ago in the last 
stage, the term occupied from the commencement to the 
fatal close of the fever did not exceed forty-eight hours; 
and it is certain, from indubitable facts,*that it sometimes 
destroys as rapidly as the plague itself.f By referring to 
the case of Martha Watson, in the appendix, it will be 
found, that a patient may be saved, by vigorous treatment, 
so late as thirty hours after a violent attack, though it is 
well known that such occurrences are rare ; yet this assur- 
ance should never make any of us desist from strenuous 
exertions, however iate we may be called in, as the most 
surprising recoveries may now and then be effected by a 
steady pei severance in proper means. 

At any time when the disease has existed more than 
twenty hours, rigors are highly alarming. But, in some ca- 
ses, there is a morbid sensibility of the surface to external 
impressions, which must not be confounded with the chills 
denoting the approaches of gangrene or suppuration, as it 
may always be distinguished from them, by the pulse re- 
maining unaltered in force and frequency. Almost imme- 
diately after copious venesection, patients sometimes 
become cold, faint, and shivery. These symptoms, 
however, need not alarm the attendant, provided the ope- 
ration has been opportunely performed, for he will then 
almost invariably find them gradually give way to a general 
warmth and moisture of the surface, succeeded by a re- 
duction of the pulse; yet if, on* the other hand, the lancet 

* When the patient had been ill for a longer space than twenty-four 
hours, before I was sent for, I generally fcund that the disease was no lon- 
ger in the power of art. \ Treatise on the Epidemic Puerperal Fever of 
Aberdeen, by Alexander Gordon, M. D. p. 14. 

"f As far as my experience goes, the same degree of fever would not 
destroy, in the same length of time, a patient not in the puerperal state, 
Indeed, scarcely any fever is known, except the plague, which has killed 
so rapidly. Dr. Johti Clarke, p. 140, 141. 

Also, consult the Treatise of Dr. Gordon, above quoted, p. 74* 



70 THE PUERPERAL FEVER. 

has been indiscreetly used, when the last stage of col- 
lapse was about to commence, or had actually commenced, 
nothing can be more dangerous than the continuance of 
the coldness, faintness, and shivering, especially if attended 
by frequent sighing, and a very feeble and irregular pulse. 

An open state of the belly immediately before delivery, 
generally tends to mitigate the severity of an early attack, 
and a diarrhoea coming on in the first stage sometimes car- 
ries off the disease* whereas, on the contrary, costiveness 
is always an unfavourable circumstance, increasing in no 
inconsiderable degree, the difficulty of the - cure. An ex- 
perienced friend of mine lately attended a patient whose 
bowels had not been loosened for more than a week before 
her labour. The case was unusually violent, and resisted 
every remedy. 

The state of the respiration, pulse, stomach, and skin 
must, in a great measure, regulate the prognosis. When 
the respirations are short, feeble, and amount to about fifty 
in the minute ; when the pulse becomes extremely weak 
and compressible, and rises above one hundred and sixty ; 
when there are frequent vomitings of a coffee-coloured 
fluid, an increase of abdominal distension, repeated shiver- 
ings, and a universally cold damp skin, the case may be 
pronounced desperate. On the contrary, when the respira- 
tion grows easy, deep, and slow ; when the puke comes 
down, and ceases to be variable ; when the stomach retains 
the food and medicine, the stools continue copious, the ten- 
sion and pain of the belly abate 5 when the skin breaks out 
into a warm sweat, the tongue becomes clean and moist, 
and especially when fresh discharges of the lochia, and 
secretion of the milk take Jilace, the symptoms fully au- 
thorize a favourable opinion?? 

Dr. Denman has stated, that a subsidence of the abdo- 
men, after copious stools, and with a moist skin, is a fortu- 
nate alteration for the patient, but that this circumstance 
without evacuation, and a dry skin, threaten the utmost 
danger.* But I have seen some cases fatal where a diar- 
rhoea came on in the last stage with a cold moist skin, and a 
subsidence of the abdominal tension. To this prognosis, 
therefore, of the judicious Denman, exceptions do exist! 

♦ See vol. ii. p. 469, of the edition before quoted. 



THE PUERPERAL FEVER 21 

As for a diarrhoea it is often a most formidable symptom, 
when it occurs in the last stage ; as it is then frequently 
connected with structural derangement of some of the ab- 
dominal viscera, and also with an universal coliapse, which 
it rapidly increases. And indeed in the first stage a diar- 
rhoea is in general no further favourable, than that it tends 
to lessen some intestinal or hepatic excitement, of which 
it is the product ; and on this account it ought never to be 
restrained at that period, as it is a most certain sign, that 
additional evacuations are requisite. 

Hippocrates has observed, that in the most dangerous at- 
tacks of fever, patients generally lie upon their backs. 
This is certainly the position which is very often assumed 
throughout the puerperal fever ; and it is commonly fa- 
vourable, when patients can turn themselves and lie upon 
the side, though I have seen some few instances where this 
was done a few hours before death. In health there is a 
certain relation between the respiration and pulse, the 
number of the former being on an average about twenty, 
and that of the latter somewhere near seventy in the min- 
ute. Any striking deviation from this relation, which is 
nearly as one of the former to three of the latter, is gene- 
rally an unfavourable symptom in acute diseases ; and we 
shall accordingly find, that this relation is sometimes com- 
pletely destroyed in the worst cases of the puerperal fever. 
But in giving a prognosis we ought never to rely entirely 
on one symptom, but take a comprehensive view of the 
whole ; so that in separating the favourable from the unfa- 
vourable signs, we may be able to perceive to which side 
the weight of probabilities inclines. 

If the pulse can be kept under 120 in the minute for the 
first week, the patients will generally do well, provided the 
respiration be not much disturbed. But if the pulse should 
continue quick after the abdominal symptoms have disap- 
peared, and if there should be evening exaeerbations, deep- 
seated suppurations may be dreaded. In general those 
patients recover the most rapidly, and are the least liable to 
secondary diseases, in which depletion has been early and 
copiously used ; but where half measures have been em- 
ployed, and where the patients have had lingering recove- 
ries from this fever, other diseases are very apt to supervene. 
Of these diseases peripneumony seems to be one of the most 



m THE PUERPERAL FEVER. 

common, from the almost general assent of authors ; but 
under such circumstances 1 have seen consumption to arise, 
indurations of the mesentric or other glands, or chronic 
inflammation in some internal or external part of the body. 
Before delivering his prognosis, therefore, the practitioner 
should endeavour to anticipate what may happen in the 
future, from a review of the present or past symptoms ; and 
in this, as in every other opinion, he should declare what 
he feels to be morally right, and be above the mummery 
and mystery of selfish cunning. As far as regards the feel- 
ings of friends, the prognosis is a point always deserving of 
the most serious consideration on the part of the practi- 
tioner ; and I may add, that it is also of the utmost im- 
portance to himself, for I never knew a medical man retain 
his popularity long, who was unguarded in the delivery of 
his prognosis. There is a principle in the human mind 
which perpetually prompts it to pry into the future : even 
to this principle much of the public inquiry respecting the 
sick may often be referred ; and people are apt to attribute 
the highest degrees of sagacity to him, who from present ap- 
pearances can predict future events. 



PREVENTION. 



WHEN puerperal fever is epidemical, the accoucheur 
should make it a point of duty to have the apartments of the 
women whom he is engaged to attend properly cleaned and 
ventilated before confinement ; to prevent nurses and other 
persons who have been with those affected, from waiting up- 
on or going near any patient about to be delivered ; to pay 
the most scrupulous regard to the cleanliness of his own per- 
son, using daily ablutions of the whole body, and frequent 
changes of linen and dress. * Though it be denied by some 



+ I had evident proofs that every person, who had been with a patient in 
Ihe puerperal fever, became charged with an atmosphere of infection, 
which was communicated to every pregnant woman who happened to 
come within its sphere. Gordon, p. 63, 64. 



THE PUERPERAL FEVER. 

authors, that the puerperal fever is always contagious, yet 
most seem to agree, that it is so under some of its modifi- 
cations ; and. therefore, it is obviously better to err on the 
side of precaution, than to pursue an opposite line of conduct. 
As anxiety of mind materially contributes to produce this 
disease, it should always, if possible, be timely allayed. 
But when the puerperal fever is known to be prevalent, 
the greatest attention and address will be requisite to re- 
move the solicitude of pregnant women ; for such is the 
constitution of human nature in general, that they are ir- 
resistibly drawn to the consideration of the existing calam- 
ity, though conscious that not to think of it would be best 
in their condition. If, therefore, an alarm be abroad, the 
practitioner must, above all things, aim to inspire the ap- 
prehensive patient with a complete confidence in his powers 
of prevention ; nor must he ever use doubtful language 
upon the subject, since, if he once betray the least fear, as 
to her security, from that moment no faith will be placed 
in his professions. 

Sedentary employments, too stimulating, or too spare a 
diet, night watcbings, fashionable dissipations, and irregular 
habits of every kind, seem to predispose pregnant women 
to puerperal fever.* A nutritious diet, early rising, and 
regular exercise in the open air, are among the most effica- 
cious means for preserving health.! and inducing an easy 
and safe labour. It did not escape the penetrating saga- 
city of Lycurgus,! the law-giver of ancient Sparta, that 
simplicity of diet, and an habitual action of the body during 
pregnancy, greatly favoured the security of the mother 
and the strength of the offspring. And I believe, that if 
these simple truths were more generally known and fol- 
lowed, there would be much less fatality in parturition. 

As the retention of fecal matter in the intestines often 
greatly assists in the production of this disease, so the 



* Mulieribus prce caeteris animalibus hoec contingunt, et prcesertium de- 
iicatis vitamque umbratilem et mollem degorc assuetis : ut et iis quae 
tenerse valetudinis sunt, et facile in morbos labuntur. Harv. Exercit. de 
Partu. 

t Verum ad sanitatem tuendaxn, si ante cibum corpora moderate ex- 
erceantur, rairuni in medum prodest, at contra quies et otium diutumum iis 
inaxinao nocumento est. Galen de Euchymia et Cacoclvymia. 

1 Consult Plutarch's Life of Lycurgus. 



24 THE PUERPERAL FEVER, 

timely exhibition of mild purgative medicines may be 
reckoned one of the best preventives. It is proverbial 
among child-bearing women, that castor oil is an excellent 
remedy for lessening the dangers incident to delivery ; and 
I have little doubt, that when the bowels have been kept 
open by it or any other suitable purgative, the occurrence 
of fever has frequently been prevented. Many pregnant 
women suppose their bowels to be in a proper state when 
they have only one scanty evacuation in the day ; so that, 
in the course of pregnancy, an extraordinary accumulation 
of feces takes place, as I have repeatedly witnessed. The 
professional person may be much deceived, who trusts to 
the reports of his patients in this respect. Nothing less 
than frequent inspections of the alvine evacuations can be 
at all satisfactory, since their quantity and appearance alone 
can regulate the extent to which purgatives should be used 
as preventives. As a general rule, to which, however, 
there may be exceptions, never less than one very copious, 
natural stool should be procured in the day, throughout 
the whole term of gestation. In a most sensible letter to 
me on the puerperal fever, Mr. Fife, of Newcastle-upon- 
Tyne, justly observes, that pregnant women are very apt 
to deceive themselves respecting the state of the bowels, 
some neglecting the use of medicine altogether, while oth- 
ers, from a fear of doing harm, content themselves by tak- 
ing now and then a little magnesia, which they imagine haF 
done enough when it produces a partial loose evacuation, 
and thus very often they lay the foundation of much future 
distress and danger. When a puerperal fever raged epi- 
demically at Aberdeen, Dr. Gordon found, that a purging 
bolus of calomel and jalap given in a morning, the day after 
delivery, either prevented the disease entirely, or seemed 
to render the attack quite manageable.* Yet upon the 
whole, I am decidedly inclined to prefer the milder purga- 
tives as preventives, but especially castor oil, which com- 
pletely unloads the bowels, without occasioning any con- 
stitutional irritation ; and this cannot always be said of the 
drastic purgatives, which, when there is no fever present, 
often excite much general irritation, and even sometimes a 
degree of tenderness over the abdomen, and thus now and 
then may probably prepare the way for what they were 

* Fee Gordon's Treatise, p. 100, 



THE PUERPERAL FEVER. 25 

intended to prevent. Under the influence of a purgative, 
women, after delivery, are easily chilled by an exposure to 
cold ; and as chillness may induce an attack, a bed-pan 
should generally be used, or, at all events, exposure to 
cold avoided. It is, 1 know from personal inquiries, the 
custom of some nurses to get the patient out of bed after 
delivery as soon almost as the accoucheur leaves the house ; 
and without his knowledge to change her linen, considering 
neither the risk which may be induced from cold, nor that 
from haemorrhage by such an imprudent exposure. Before 
leaving his patient, therefore, the accoucheur should give 
the most particular directions, equally stating what ought, 
and what not to be done, till his nest visit. 

During labour, care should be taken not to irritate the 
os uteri by frequent and unnecessary examinations ; nei- 
ther ought the placenta to be extracted too hastily, for 
much mischief may result from such a procedure ;* 
haemorrhages may immediately follow, the uterus itself may 
receive some serious injury, or it may contract -upon a 
small portion of the placenta left attached to its interior, 
any of which things may act as an exciting cause in a per- 
son predisposed to this fever. My respected friend, Mr. 
Ferguson, of Bishopwearmouth, who has been in a most 
extensive practice of midwifery, for about forty years, has 
hardly ever seen puerperal fever succeed uterine effusions 
merely arising from a defect of contractility in the uterus, 
but has often seen it follow those haemorrhages which arose 
from an injury sustained by that organ. This is an import- 
ant fact, and perhaps may, in part, tend to explain some of 
the existing discrepancies of authors, some of whom assert 
that floodings occasion,! and others that they prevent, the 
disease }J at all events it suggests the propriety of using 
prophylactic measures, where large discharges have taken 
place after difficult labours, or in consequence of violence 

* Rude treatment of the os uteri, and a violent or hasty separation of 
the placenta, will often give rise to this disease. Denman, vol. ii. p 461. 

* Mr. White on the Management of Pregnant and Lying-in- Women, 
p. 219 — Dr. Manning on Female Diseases, p. 371. 

J Those gentlemen themselves know best on what foundation their 
opinion is grounded ; but, for my part, I found that large uterine effusions 
invariably prevented the epidemic Puerperal Fever which I have de- 
scribed* Gordon, p. 111. 



26 THE PUERPERAL FEVER. 

suffered by the uterus. It is not, I hope, presuming beyond 
my province, when I admonish accoucheurs in general not 
to let the pressure of business induce them to extract the 
placenta too soon ; nothing but an eruption of blood, threat- 
ening the very life of the patient, can justify its hasty and 
forcible separation. On the other hand, the after birth, 
for obvious reasons, must not be allowed to remain too long. 
Dr. Hamilton, the judicious professor of midwifery in the 
University of Edinburgh, declares, in his lectures, that it 
cannot be left, with perfect safety, longer than an hour in 
the uterus, after the expulsion of the child.* From exten- 
sive inquiries which I have made amongst practitioners in 
midwifery, it would certainly seem, that haemorrhage dur- 
ing delivery does in certain subjects predispose them to 
attacks of the puerperal fever ; and it was an observa- 
tion of the late Dr. Clark, of Newcastle-upon-Tyne, who 
had seen numerous examples of this disease, that uterine 
haemorrhage had preceded the majority of the attacks. 
What is called arterial re-action, an increase in the action 
of the heart, with an increase of the animal heat, is very 
liable to follow large losses of blood ; and when we con- 
sider, that those losses must have weakened the system, it 
will not aprear surprising that the subsequent re-action 
should lead to abdominal inflammation in peculiar habits. 
Probably different men may have been led to different con- 
clusions, respecting the influence of uterine haemorrhage, 
from the various modes of treatment afterwards adopted $ 
those perhaps who pursued an antiphlogistic plan, having 
rarely seen this disease to supervene ; and those who pur- 
sued a different method, having often marked its occur- 
rence. Considerable mischief is often produced by at- 
tempts to raise the prostrate powers at once by the exhi- 
bition of diffusible stimulants : but where life is not in 
jeopardy from the collapse, it is always best to endeavour 
to raise the system gradually into vigour by mild means : 
for under this plan we shall generally avoid any secondary 
affections of excitement, whereas, under the other, those 
affections will not be uncommon. 

* Ai 1he life of the patient is never exempt from danger til! the after- 
birth he extracted, no practitioner ought on any pretence to leave a wo- 
man even for a short space of time till *hat circumstance has taken place. 
Hamilton's Treatise on the Management of Female Complaints, fiftli 
petition, p. 188. 



THE PUERPERAL FEVER. 27 

If cold has been applied to any great extent in uterine 
flooding*, and a considerable re-action of the heart and ar- 
teries> with some degree of fever, is likely to succeed their 
suppression, the practitioner must be upon his guard, and 
not permit his patient to take strong drinks and food by 
way of replenishing the system ; but he must insist upon a 
cooling regimen, and administer aperients till the inflamma- 
tory threatenings disappear. After severe, and especially 
after instrumental labours, two or three visits should be 
daily paid to the patients for some time by the professional 
attendants., that they may have proper opportunities of en- 
forcing their directions, and of perceiving the very first ap- 
proaches of any fever that may supervene; but indeed, a 
spare diet, cleanliness, ventilation, quietness, and ari oc- 
casional purge, will generally obviate danger. Dr. Den- 
man notices that women are certainly not so often attacked 
with this fever after difficult labours, because of the parti- 
cular care with which they are then managed; whereaSj 
after easy ones, they are more unguarded.* That the bo- 
dy will bear a great deal without serious consequences is 
certain, when precautionary measures are early adopted 
and steadily pursued. I was once consulted where, from 
inflammation, the os uteri during pregnancy had complete- 
ly and firmly united by a sort of ligamentous substance; 
so that the accoucheur had to make an incision there by 
the knife before the child could be removed from the ute- 
rus ; and yet, in this remarkable case, the woman had an 
exceedingly good recovery, a strictly antiphlogistic plan 
having been enforced for some time after the operation. 

Celsus,t and other writers since his day, have recom- 
mended patients to be treated, for a certain time after de- 
livery, as if they actually laboured under an inflammatory 
affection, or had received some wound in an important part 
of the body. In reality, no advice can be more judicious 
or necessary, however it may be disregarded in ordinary 

* See his work, vol. ii. p. 463. 

f Reliqua curatio talis esse debet, qualis in inflammationibus, et in his 
vulneribus, quae in nervosis locis sunt, adhibetur. A. Corn. Celsus. 
Glasgua? : Excudebat Gulielmus Bell, mdcclxvi. Vide p. 357. 

Women in child-bed ought to be managed not only as persons sorely 
wounded, but as having gotten a feverish indisposition. Willis, p. 636, 



28 THE PUERPERAL FEVER. 

practice. The species of inflammatory diathesis which e%~ 
ist-s throughout the whole period of pregnancy,* together 
with the throe^ of parturition, bring the system into a state 
verging upon *febnie excitement, which no doubt would 
be attended with considerable danger, were it not for the 
secretion of the milk, and the flowing of the lochia. If, 
therefore, we would lessen the risk of fever in general, and 
of the puerperal fever in particular, the child should not be 
kept from the breast longer than twelve hours from the 
time of its birth; we should enjoin the strictest antiphlo- 
gistic regimen, and administer mild purgatives now and 
then, especially during the first four or five days, as that 
appears to be the term in which there is the greatest ten- 
dency to febrile disorders.! Every thing calculated strong- 
ly to excite should be withdrawn, such as noise, light, and 
heat. And at the same time that the room should be kept 
at a moderate temperature and properly ventilated, we 
should be particularly careful to prevent currents of cold 
air from passing over the bed of the patient, for the reasons 
already mentioned.! 

The use of cordials cannot be too positively and repeat- 
edly prohibited, since it is not uncommon for nurses to give 
the patients whom they attend a cup of burnt brandy" or 
caudle after delivery, and to add to the sago or gruel, which 
always ought to be taken in the simplest" form, large por- 
tions of strong wine. And it is melancholy to think that 
such things are sometimes done expressly against the com* 
mands of medical practitioners. The deceptions practi- 
sed by those persons, commonly called old experienced 
nurses, are hardly credible. In the presence of the physi- 
cian, they will seem very desirous to carry all his orders in- 
to effect 5 but in his absence, either accommodate them- 

* Hunter affirms that the blood is always sizy in breeding women. See 
a Treatise on the Blood, Inflammation, &c. By the late John Hunter. 
In two volumes. London, 1812, Vol. ii. p. 69. 

t The pernicious custom of binding the body too tight ought also to be 
avoided ; as it will produce difficulty of breathing, hcad-ach, and op- 
pression at stomach. Leake, p. 139. 

J There is nothing so great an encmic to a woman in travail, especially 
to her whose childe is drawn away by violence, as cold. And thereof coin- 
meth manie grievous accidents, as hysterical suffocation, painful fretting 
of the guts, fevers, and other mortall diseases. Johnson's Translation or" 
the Works of Ambrose Parey. Printed in 1649. See p. 613 



THE PUERPERAL FEVER. 29 

selves to the whims of the capricious, or, appealing to 
their long experience, persuade the timorous patient to 
take a diet very different from that directed ; and thus, 
between the hypocrisy of the one, and the weakness of the 
other, the d^r v]l t | s successfully carried on, unless danger 
or accident should reveal it. The lives of many women, 
and *he reputations of many accoucheurs have, I am fully 
confident, been sacrificed in this way. Whenever, there- 
fore, professional men detect any thing like duplicity in the 
conduct of nurses, they should act in the most authorita- 
tive manner, immediately insisting upon their dismis- 
sion ; for it may be regarded as a moral rule, to which 
there are few exceptions, that persons who once delibe- 
rately commit a dishonourable action can not be trusted 
with safety a second time. 

Mismanagement in nursing is not confined to the higher, 
but extends to the middle and lower ranks of life, in which 
it has become an almost established custom to give distil- 
led spirits and a flesh diet to women in child-bed.* Be- 
sides, in the first week of confinement, the rooms are crowd- 
ed with a succession of friends and visitants, who generally 
converse, over a large fire, until a late hour at night. As 
improprieties of this nature are often followed by disa- 
greeable, and sometimes by fatal consequences to the sick, 
they cannot be too publicly and frequently exposed. 

If, notwithstanding every possible precaution, there 
should be the slightest accession of fever after parturition, 
and especially if the puerperal fever be prevalent at the 
time, or there be any circumstances in the patient which 
predispose to its attack, we ought to be extremely atten- 
tive 5 as any fever may pass into the puerperal, particular- 
ly where great anxiety and irritability exist, because the 
main force of the general excitement will be liable to fall 
upon the abdominal viscera, from the peculiar state of the 
vessels there at that period. t 

*I have diligently observed that an "over-hasty eating of flesh, or of rich 
food, has oftentimes brought these fevers. Willis, p. 636. 

f After labour, the cavity of the abdomen is in part debilitated, from 
the great change it has undergone in passing from a state of great tension 
to a state of great flaccidity ; and if the woman catches cold, or receives 
infection, the mischief falls on the abdomen, as on the weaker part. The 
Anatomy of the Absorbing Vessels of the Human Body, By William 
Cruiksbank. Second edition, p. 119. 



m THE PUERPERAL FEVER. 



PATHOLOGICAL REMARKS. 

AFTER what has been said, it may be thought by some, 
that I ought to endeavour to find out the cause from which 
this fever immediately proceeds and derives its specific 
character ; but when I reflect how little is known about 
proximate causes, and how great the uncertainty of all 
reasonings a prioii, I am induced to avoid this part of the 
subject, especially as I conceive it to belong rather to met- 
aphysical, than to medical science. Such discussions in- 
deed are far from being generally satisfactory, and, even 
when most ingeniously conducted, perhaps not more prof- 
itable than the long agitated disputes of the schoolmen^ 
respecting the essences of things, which, in some respects, 
they seem to resemble. The history of medicine, like that 
of every other science, clearly shows that conjectures have 
seldom led to useful discoveries; but, on the contrary, 
have often allured from the investigation of facts, to the 
consideration of those obscure and disputable relations 
which things unknown bear to the known phenomena of na- 
ture. It has been well observed, by a sensible anonymous 
writer, that in physic, more than in any other department 
of human knowledge, facts are every thing, and theory no- 
thing.* It is, therefore, my determination not to connect 
hypotheses with the plain evidences of symptoms and dis- 
sections, by which, in my opinion, a true knowledge of 
pathology can alone be established, and from which my ob- 
servations shall be chiefly drawn. 

If an unprejudiced practitioner were called to attend a 
woman shortly after parturition, and found her labouring 
under an oppressive fever, the abdomen painful and dis- 
tended, the skin hot, ihe tongue dry, the pulse very quick, 
ihs breathing burned, and the secretions probably dimin- 
ished or suppressed ; and further, if he finally saw his pa- 
tient fall a victim to the complaint, and, on accurately dis- 
secting the body afterwards, discovered the most extensive 
traces of an abdominal inflammation, without any other ap- 
pearances sufficient to account for death, he would at once 
conclude that the disease was of an actively inflammatory 

* See ihe Elcctic Review for October, 1813, vol. x. p. 343. 



THE PUERPERAL FEVER. 31 

nature, and would determine for the future to treat it, and 
every similar affection, with the greatest promptitude and 
decision. Such a conclusion and determination I would 
most earnestly recommend every medical man to form ; 
first, because there is perhaps no disease more uniform than 
puerperal fever in the symptoms and morbid derangements 
which it induces ; and secondly, because it can only be 
combated with the probability of success by antiphlogistic 
means. Almost every writer of eminence on the puerpe- 
ral fever has recorded the uniformity of the symptoms and 
morbid derangements ;* and to prove the propriety and 
usefulness of the antiphlogistic methods of cure, I might 
appeal to the works of Mauriceau, Burton, Peautau, He- 
berden, Denman, Hulme, Leake, Gordon, and Hey, which 
constitute a satisfactory train of evidence upon the sub- 
ject. Were I inclined, too, I might here also avail myself 
of the great candour of those authors who have treated pu- 
erperal fever as a putrid and typhoid distemper, their im- 
partial and disastrous reports forcibly demonstrating that 
stimulants, so far from answering a good purpose, are most 
decidedly prejudicial. 

Some writers, of deserved celebrity, having considered 
the low fever of child-bed, which is sometimes epidemic, 
as specifically distinct from the puerperal peritonitis, it be- 
comes, therefore, a matter of great practical consequence 
to ascertain whether symptoms and dissections justify such 
a distinction. 

In the low fever of child-bed, pain, tenderness, and ful- 
ness of the abdomen, are generally discernible in the be- 
ginning ; there is, likewise, a quick pulse, and preturnatu- 
ral heat, all of which symptoms appear in the puerperal 
peritonitis. But in the low fever, as it is termed, we find 
a weariness, greater prostration of the animal functions, an 
overpowering oppression of the whole system, which are 

* The operations of nature upon the human frame, in this disease, are 
the same in Britain, as in Greece ; and continue the same at this day, as 
they were above two thousand years. This is likewise a clear proof of 
the immutability of puerperal fever, that it is an original disease, and hath 
been prevalent at all times, and in all climates. Hulme on Puerperal Fe- 
ver, p. 96. 

Also, respecting this point, consult Leake, vol. ii. p. 43 ; Home's Clini- 
cal Experiments, p. 67 ; Gordon, p, 5, 6, 117, 118; anil Mr. Hey's ex- 
cellent Treatise on this disease. 



32 THE PUERPERAL FEVER. 

not so apparent in the puerperal peritonitis, and which, to- 
gether with the sometimes epidemical character of the for- 
mer, have been thought sufficient grounds for classing it as 
a separate and distinct disorder. But, passing from symp- 
toms, let us endeavour, by dissections, to develope the 
true nature of this disease. 

All the anatomical examinations which have been made 
on the bodies of those who died of the low fever of child- 
bed, incontestibiy prove that if there be any difference be- 
tween it and the puerperal peritonitis with regard to their 
inflammatory disposition, that difference merely consists in 
degree, the vestiges of inflammation being more strikingly 
evident, and extensively destructive in the former, than in 
the latter. For the truth of these affirmations, I refer, in 
particular, to the writings of Denman, Leake, Home, 
Hulme, Clarke, and Gordon, in which it will be found that 
the viscera of the abdomen — the peritoneum, the oment- 
um, the mesentery, the mesicolon, the liver, the stomach, 
the small and large intestines, the uterus and its appenda- 
ges, the bladder, and even the pleura, and the lungs them- 
selves, have all, in their turn, been more or less affected by 
the inflammation attendant upon what they considered the 
true puerperal fever, or what others have called the low 
fever of child-bed.* 

It has been demonstrated by the accurate dissections of 
the late highly gifted Dr. John Clarke, that several quarts 
of a serous fluid, and large portions of coagulable lymph 
have been effused, in the course of a few days, into trie 
cavity of the belly, during the progress of the low child-bed 
fever, and that, in those instances, the vestiges of inflam- 
mation left on the abdominal viscera, were by no means 
proportionate to the quantities of fluid and solid matter ex- 
travasated. These appearances led that enlightened phy- 
sician to suppose, that the effusion \yas not the effect of ac- 
tive inflammation, but of a certain disposition of the vessels 

♦If the reader should be desirous of consulting the authors alluded to 
here, respecting the morbid states induced by the puerperal fever, -the 
followins references may save him some trouble. Dr. Denman, vol. ii. p. 
494, 405. Hulme, p. 37, 38, 40, 41, 42, 43, 45, 46, 48, 53, 54, 55, 56. Fos- 
ter, p. 296, 297, 298. Leake, vol. ii. p. 1 1, 106, 180, 181, 182, 197, 198, 
199, 209, 210> 227, 228, 240, 241. Home's Clinical Experiments, p. 73, 
77. Dr John Clarke, p. 80, 81, 123, 124. Dr. Gordon, p. 31. 40, 118. 



THE PUERPERAL FEVER. 33 

of the parts affected, specifically distinct from an inflam- 
matory action. The properties of this fluid, however, the 
coagulable lymph every where covering the intestines, and 
tilling up their interstices, and the pain and general excite- 
ment which attended the previous disease, considerably 
lessen the force of this conjecture ; and it will also appear 
the more improbable when we reflect, that the extravasa- 
tion of so large a portion of serous fluid and curd-like mat- 
ter would necessarily tend to obliterate the strong charac- 
ters of inflammation, on the surface of the viscera and 
linings of the abdomen, in some cases, and, in others, to 
render those characters less distinct than they would have 
been, provided a more inconsiderable exudation had taken 
place.* It is an indisputable fact, that inflamed internal 
canals and membranous surfaces often pass, with great ra- 
pidity, from the first state of inflammation, into the suppura- 
tive or effusive action.! Very considerable suppuration is 
occasionally found, on the membranes of the brain for in- 
stance, with hardly any vestiges of an increase of vascular 
action : but would any person deny, or has any person even 
conjectured, that this could take place without previous in- 
flammation ? If it be here objected that suppuration is not 
effusion, and that, therefore, the cases are not analogous, 
it is readily granted that suppuration is not effusion ; but 
it cannot be disputed that these are two of the ways in 
which inflammation terminates ; and if we always infer the 
existence of inflammation in the one case, how can we, in 

* If an inflammation arise in a cavity, it may terminate in a number of 
different ways : one of these ways is by an increased secretion of the fluid 
of surfaces. A man receives a blow on the testicle ; inflammation takes 
place, and the consequence is frequently a hydrocele, or dropsy of the tuni- 
ca vaginalis. A child's brain inflames, and this inflammation ends at last 
in hydrocephalus, or collection of water in the brain. Pleurisy frequently 
terminates in hydrothorax, or collection of water in the chest. I have of- 
ten taken away forty or sixty pints of water which had accumulated in the 
cavity of the abdomen, in the few days the peritoneal inflammation- had 
lasted, during the usual species of child -bed fever. Cruikshank on the 
Absorbing Vessels, p. 146. 

f In inflammation of membranous parts which in health secrete a parti- 
cular fluid, a liquid different from pus, and resembling more the natural se- 
cretion of the part, is formed. In this, as in the other case, the inflamma- 
tion diminishes ; but the patient has seldom any chills, nor is the structure 
of the part injured, at least further than by mere distension, if it be a cavi- 
ty. John Burn's Dissertation on Inflammation, vol. i. p. 289, 290 

6 



34 THE PUERPERAL FEVER, 

considering the puerperal fever, fairly deny it in the other I 
In short, it appears to me physically impossible that any 
thing but a highly active inflammation could occasion, in 
the short space of five or six days, so large a collection of 
serous fluid and coagulable lymph as that sometimes found 
in the cavity of the abdomen, after the fatal termination of- 
the low child-bed fever. 

In discussing this question, it might reasonably be expect- 
ed, that I should give some account of those dissections 
which my own experience has afforded, after the fatal issue 
of what might be deemed the true puerperal fever. In all 
of those dissections which I witnessed, the most unques- 
tionable proofs of abdominal inflammation existed; and 
the same has been invariably observed in many examina- 
tions made by some of my professional friends, in fatal ex- 
amples of the hospital puerperal fever. In addition to these 
facts, the evidence of the able conductors of the Medical 
Review and Register may be adduced. They examined 
the bodies of thirteen women who died within a short 
space of time. In every instance the peritoneum was in- 
flamed, and covered, as well as the surface of the intestines, 
with a layer of coagulated lymph, while a quantity of whey- 
like fluid was effused into the cavity of the abdomen.* 
Some go so far as to pretend, that the puerperal fever can- 
not be the same as the true puerperal peritonitis, because 
in the former the peritoneum which lines the anterior surface 
of the abdominal cavity, and which is not immediately attach- 
ed to the viscera, has been found uninflamed, but this is at 
best the quibbling evasion of an embarrassed disputant ; for 
dissections discover, that some portion of this membrane 
has been invariably inflamed when traced throughout its 
whole extent, though certainly other parts, as in other fe- 
vers, are liable to suffer from the general excitement. 
From all that has been advanced, then, it may be laid 
down as a general proposition, that abdominal inflamma- 
tion directly or indirectly is the cause of the fatal termi- 
nation of all the varieties of the puerperal fever. But 
though I have strenuously contended, that the puerperal 
peritonitis, and the low child-bed fever, may be patho- 
logically considered as modifications of the same disease. 

* See the Annual Medical Review and Regiiterfor 1809, vol. ii, p. 27$ 



THE PUERPERAL FEVER. 35 

yet I have avoided the term identity, because I have no 
inclination to enter into abstract discussions, or nominal dis^ 
putes. Nor will i take upon me to assert, that there is al- 
ways a perfect sameness, since there necessarily must be 
such a difference as arises from the peculiarities of the pa- 
tients, from the parts within the abdomen most decidedly 
attacked, and from the influence of the seasons and other 
circumstances. Nay, I have no objection to grant, that the 
inflammatory character of this disease sometimes conceals, 
and even appears to lose itself in an almost unequalled pros- 
tration of the powers of the system. What I wish, however, 
particularly to insist upon is this, that the low child- bed fe- 
ver, and the puerperal peritonitis, are so far the same as 
to require the depletory practice ; only in the former this 
practice must be more promptly and powerfully applied^ 
as the time in which the professional man can be useful 
is much shorter, on account Qf its greater intensity. 

It cannot be denied by any one, that the disease which I 
have delineated in the beginning of this work deserved the 
name of an epidemic, in the most strict sense of the word ; 
and yet some cases of that epidemic bore the character of 
a simple inflammation of the peritoneum, and others again 
assumed a more mixed and malignant character, from 
the greater depression of the general powers. It was the 
certainty of this fact, together with the disease being re- 
markably limited to the practice of certain individuals, 
which mainly induced me to believe, that it was contagious; 
and reasoning from the similitudes in the cases which had 
previously come under my observation, and from the gen- 
eral analogies in the laws of febrile diseases, an inference 
was drawn precipitately, that the puerperal fever is invaria- 
bly of a contagious nature. So many experienced corres- 
pondents, who had no theory to support, have spoken so 
confidently of the non-contagious character of the puerpe- 
ral fever under its ordinary or sporadic form, that it would 
be presumption in me to suppose them mistaken rather 
than myself;* and if the puerperal fever be not contagious 

* It is with the greatest pleasure, that I publish the valuable communi- 
cation of Dr. Joseph Clarke in the appendix, because it contains the open 
and honourable expressions of an independent mind ; and as some of those 
expressions, especially on the subject of contagion, bear directly against 
some opinions advanced in the first edition of this work, they may be 
highly useful by turning the attention of others to the points of discrepancy 



36 THE PUERPERAL FEVER. 

when it is sporadic, it becomes a most interesting question 
to ascertain, whether or not it be contagious when it is epi- 
demic. Many of the causes of fever, especially those 
connected with certain states of the atmosphere, are in- 
volved in so much obscurity as often to leave room for con- 
siderable doubt ; and it seems as if it were almost a principle 
of our constitution, that rather than vacillate long in doubt, 
the mind will rest even upon error. Hence in things high- 
ly interesting to us as moral and intellectual beings, we 
often rind that repose in some dogma, which we in vain 
sought for in the deliberations of philosophical inquiry ; 
and hence too, in what relates to the explanation of the 
more subtile causes of our physical disorders, we perhaps 
too frequently have recourse to contagion for a solution of 
some perplexing difficulty. Two of "the gentlercjen in 
whose practice the puerperal fever appeared in the north 
of England, (Juring the year 1813, became so fully assured 
of their conveying the contagion, that they withdrew from 
their professionaf;rvocation for a time ; and though at that 
period an equally confident impression was made upon my 
mind, as to the infectious property of the disease, yet I 
shall not now draw any inference on the subject from the 
facts recorded, but leave them for the consideration of 
others, who may be disposed to accumulate evidence on a 
point so important. An attentive perusal of various trea- 
tises, and a cautious survey of those cases which I have 
myself seen, would authorize me to conclude, that the 
puerperal fever may proceed from a variety of causes ; 
and future observation will probably bear me out in affirm- 
ing, that any circumstance which gives a general shock to 
the system, is fitted to produce the disease in habits already 
predisposed. But if it be asked, why a variety of causes 
should produce the same effect, we must look to the pecul- 
iar condition of the abdomen at the time of their applica- 
tion : for it must again be repeated, that if a general 
excitement occur, the principal mischief of that excitement 
will be most liable to happen where the state of the circu- 
lation had been previously most disturbed ; and this is a 
pathological doctrine of such extensive application, that 
some pains shall be taken to illustrate it, in an essay which 
will shortly appear in an emended edition of my treatise on 
typhus. 



THE PUERPERAL FEVER. 37 



TREATMENT. 

NO medical man can be ignorant of the great diversity of 
treatment which has been pursued in the puerperal fever. 
Being persuaded that much of this diversity proceeds from 
want of a proper regard to the distinctions between the 
itageof excitement and the stage of collapse, the reader must 
excuse me for again briefly reverting to those distinctions ; 
as it was repeated observations of the disease as existing 
under two different states, that led to the discovery of those 
principles which have been fourjd at once simple and 
adapted to the nature of the complaint. 

The puerperal fever is sometimes ushered in by a rigor, 
and sometimes merely by some degree of preternatural 
paleness of the surface ; but in both cases there is a dimin- 
ution in the force of the pulse, and also more or less di~ 
minution of the animal heat. This stage ought to be ac- 
counted the first, because it almost invariably precedes 
what is usually called the re-action, or the establishment 
of the true febrile state. But as this obscure stage is com- 
mon to other affections, and as the character of the puerpe- 
ral fever cannot, in general, be said to be truly declared till 
the re-action exist, the occurrence of that re-action, and 
its continuance to its highest point, shall be denominated 
the stage of excitement ; and on the other hand, the mark- 
ed declination of that excitement, and the symptoms of 
constitutional exhaustion which supervene, shall be denom- 
inated the stage of collapse, for the purpose of more forci- 
bly contrasting the different states of the system in these 
two stages. 

As soon as the heat becomes greater and the pulse 
quicker than natural, the stage of excitement may be pro- 
nounced to be established. In this stage the skin is com- 
monly dry as well as hot ; but in some instances it is par- 
tially damp while it is universally hot, and this is particularly 
liable to happen where the pain is violent, or where the 
stomach is atfected with nausea or vomiting. The pulse is 
hardly ever less than 120 during this stage, and in some 
rare cases as high as 140 in the minute, or even higher. 
In general the blood does not flow in a soft, easy, tranquil 



33 THE PUERPERAL FEVER. 

current, but comes against the finger with a vibratory sort 
of motion ; and more than ordinary pressure is commonly 
requisite to stop its course along the artery, which in such 
cases feels hard and tense, like a cord upon the stretch, 
Yet there are some instances in which the pulse is very 
quick, and peculiarly soft and compressible, from the first 
occurrence of the stage of excitement ; though this, so far 
from being more favourable, is considerably more danger- 
ous than the hard resisting pulse, for it marks a relaxation 
of habit highly to be dreaded in every form of fever. In 
this stage, too, the patient complains most of the abdominal 
pain and soreness, breathes above thirty times in the min- 
ute, and rather anxiously, has a white foulish tongue, con- 
siderable thirst, and much febrile restlessness and irritation. 
The belly is generally bound, and bile or mucus vomited 
in some cases ; but in others the stomach is little disturbed, 
though its powers in most are prostrate. 

In the stage of collapse, the pulse always becomes ex- 
ceedingly weak and small, and in most cases is above 140 
and in some above 160 in the minute ; though in two, which 
I attended since the first edition of this work was publish- 
ed, me pulse feil somewhat below 100 a few hours before 
death, still continuing very thready to the last. The res- 
piration generally becomes much quicker, shorter, and 
weaker in this than in the preceding stage ; so that it is 
not uncommon to see some patients breathe above fifty 
times in vhe minute : but I have known a few cases, where 
the brain was embarrassed, in which the respiration became 
very slow and impeded before death. On the supervention 
of this stage, the heat begins to decline, and is not equably 
diffused over the surface, as in that of excitement. Cold 
partial perspirations first break out about the face, neck, 
and extremities ; the central parts of the body often re- 
maining dry, and of a superficial giow, for some time after- 
wards. Ti»- patient now mostly vomits both her food and 
medicine, which are apt to be tinged with a dark grumous 
matter; and the belly is commonly loose from the com- 
mencement of this stage, and the abdomen much distended 
with ilatus. The tongue in some cases has a brown or 
blackish appearance, in others it is red, rough, and parched; 
but where there is much fluid vomited, it is often moist, 
and has a pretty natural appearance. The thirst is gene- 



THE PUERPERAL FEVER 39 

raiiy unquenchable in this stage, and the patient becomes 
less and less capable of assisting herself by voluntary ef- 
forts. The countenance is sunk, yet often agitated, the 
face and lips cadaverously pale, and the alae nasi in almost 
unceasing motion ; while the patient lies flat upon her 
back, often moving her hands and drawing up her feet, or 
now and then unexpectedly throws herself into some strange 
attitude. There is often much moaning or muttering in 
this stage as if great uneasiness existed which, however, is 
seldom referred, on questioning, to any particular part ; 
but several hours before death, the sensorial functions are 
in general some way disturbed, and the skin becomes re- 
markably relaxed, damp, and cold. In fine, the stage of 
excitement is marked by inflammatory, and the stage of 
collapse by low malignant symptoms ; and the degree of 
the latter is almost invariably in proportion to the degree 
of the former. 

Perhaps scarcely any of the above symptoms, taken 
singly, can be depended upon as distinctions between the 
stage of excitement and that of collapse ; yet as several of 
them accompany or succeed each other, they may together 
enable the practitioner to discriminate each of these states 
in the puerperal fever. The stage of excitement is variable 
as to its duration, being regulated by the degree of the gen- 
eral fever, and of the local affection. Sometimes it termi- 
nates in twenty hours, and at other times extends to seventy, 
even when the inflammation is of the acute kind ; but in 
that slow modification where the general fever is not ur- 
gent, and where the abdominal inflammation is sub- acute, this 
stage may be much more protracted. The period of time, 
too, w r hich the stage of collapse occupies, is likewise very 
uncertain. If it be accompanied by gangrene in some of 
the viscera, it does not last many hours, and if by suppura- 
tion, it is generally mortal in a few days : but where it is 
accompanied, as generally happens, with an effusion of se- 
rous fluid and coagulable lymph into the abdomen, it may 
occasionally continue a longer time ; and though in some 
rare instances it may even present the possibility of recov- 
ery, yet it is commonly soon fatal, -from the exhaustion 
and irritation with which it is combined. 

In the earlier part of my practice, being consulted in the 
last stage of some cases of puerperal fever, more than once 



40 THE PUERPERAL FEVER. 

I was surprised to find the abdomen soft and painless, and 
the countenance little discomposed, when the clayey cold- 
ness of the extremities, and the quick, liny, irregular pulse 
warned me that the patient had not many hours to live. If 
no accurate history of such cases could have been obtained, 
it is not impossible but I might have concluded, that the 
disease was most decidedly of the asthenic order, requiring 
wine and cordials throughout ; but, on minute and repeated 
investigation, I then found, as I have since in similar cases, 
that this general prostration of the system was preceded 
by febrile excitement and pain, in short, by symptoms of 
abdominal inflammation. For the most part, physicians are 
not consulted till the disorder has advanced into the last 
stage, in which blood-letting is so certainly destructive ; and 
some authors having formed their opinion from the appear- 
ance of disease, and the ill effects of venesection at this 
period, seem thus to have been persuaded, that debility was 
the principal thing to be counteracted throughout. 

In the treatment of all febrile diseases, and of the puer- 
peral fever in particular, it is of the greatest consequence 
to distinguish between apparent and real debility, between 
a state of the system in which the general powers are de- 
pressed but not subdued, and an opposite state of collapse, 
in which those powers are absolutely and exceedingly 
weakened : for in the former case, what appears to be a 
state of debility can only be removed by depletion suffix 
cient to take off the load by which the strength is suppres- 
sed ; but in the latter case, the period for depletion, at 
least by the lancet, is completely past, and the prostrate 
powers must then be sustained by invigorating measures. 
In the epidemic which occurred in the north of England, 
there was. an appearance of excessive debility in many 
cases soon after the attack ; but in all it was purely an ap- 
pearance of debility in the beginning ; in a word, an oppres- 
sion dependent upon the general excitement and topical 
inflammation. In the last stage, however, the debility was 
altogether of a different description, being then connected 
with general exhaustion and general irritation — the mere 
consequences of the unrestrained excitement and inflam- 
mation, which had previously taken place. 

If I might be allowed to judge from my own experience. 
it may be laid down as a general principle, that the abdo- 



THE PUERPERAL FEVER. 41 

minal inflammation is greatest in*those cases of the puerperal 
fever which are attended, from the beginning, by most op- 
pression of strength, and of the vital powers ; and it will 
be found a most fatal delusion to be deterred from early 
bleeding and purging by the semblance of debility, which 
only serves as a covering to obsGure the destructive pro- 
gress of the abdominal inflammation. It was indeed this 
semblance of debility which deterred some practitioners 
from the employment of the lancet, in several of the most 
formidable cases which occurred ; and it was only a fatal 
experience which convinced them of the mistake, and 
which determined them to adopt an active practice, in op- 
position to the prejudices imbibed at the schools. In the 
beginning, the puerperal fever may be considered as an 
alarming irregularity of the system, capable however of be- 
ing generally corrected by prompt and decisive means ; but 
in the last stage, the functions or structure of the grand ma- 
chinery of life are so much deranged as to be utterly irrepa- 
rable. The puerperal fever, under every form, will only 
be found remediable in the stage of excitement ; at least 
nothing can be done with the probability of success when 
the general collapse supervenes. It is in the commence- 
ment only, that the inflammatory symptoms are manifested; 
and when the excitement has passed its acme then come 
the malignant symptoms, which have been supposed to con- 
stitute the essence of the low child-bed fever ; but in fact 
these symptoms are nothing more than the effects of that ex- 
citement, and therefore the term low child-bed fever is cal- 
culated to convey very erroneous notions of the nature of the 
disease, being in strictness only applicable to the last stage. 
These observations may serve to show how dangerous 
are the opinions of those who recommend stimulants from 
the very onset of the puerperal fever ; since such agents 
must necessarily increase the irregularity in the system 
during the first stages, and thus contribute to hasten that 
derangement of the vital organs which is, directly or indi- 
rectly, the cause of death in the last stage. The advo- 
cates, indeed, for the stimulant treatment have been so can- 
did as to confess, that it has rarely been attended with the 
desired success, by far the greater number of their pa- 
tients having sunk under its employment. Yet so far from 
conceiving, that the treatment was in any manner concern- 

7 



42 THE PUERPERAL FEVER. 

ed in this awful fatality, they have attributed every thing 
to the irremediable nature of the disease; nay, they have 
gone even further, and in their zeal against innovation, 
have condemned the depletory practice, without even hav- 
ing given it a fair trial. Some men come to the conside- 
ration of important subjects with a creed and a character 
which they had passively but deeply received ; and such 
men seldom view things as they are actually regulated in 
nature, but in general according to the prescriptions of 
their predecessors. The most authentic records, howev- 
er, in regard to the puerperal fever, if impartially examin- 
ed, do go to demonstrate, that evacuants have been gene- 
rally successful when properly used ; and it may be safely 
asserted that, for the most part, they have only failed when 
they were not employed sufficiently early, or not carried 
sufficiently far, as might be proved by references to Leake, 
Hulme, Denman, Gordon, and other authorities. It is still 
the constant cry of many, that you must refrain from deple- 
tion in the beginning of fevers, by way of preserving the 
powers in the advanced stages ; but this is a doctrine alike 
dangerous to the reputation of the practitioner, and to the 
life of the patient : for the best way of sustaining the pow- 
ers in the advanced stage of fevers, is to cut short or re- 
duce the excitement in the first ; and to withhold the meas- 
ures which do this, is to expose the subjects of fever to the 
chances of fatal derangements in the structure or functions 
of the vital parts within. 

During a residence of several years in Sunderland, some 
cases of the puerperal fever, chiefly occurring among the 
poorer inhabitants, annually came under my care. For 
the most part, my opinion was not requested till the dis- 
ease had existed some days, and I found that whatever plan 
was pursued, the event was generally disastrous. Blood- 
letting invariably sunk the feeble remains of life with great 
rapidity; a liberal allowance of wine and cordials was, if 
possible, more speedily destructive; and although purga- 
tive medicines, and a nutricious diet, protracted, they sel- 
dom saved the life of the patient. Being fully aware of 
the inflammatory nature of the puerperal fever in the first 
instance, when called early, I almost always ordered one 
venesection from a large orifice, cathartics daily, and a 
spare diet during the continuance of the urgent symptoms. 



THE PUERPERAL FEVER. 43 

In the main run this practice succeeded, though now and 
then a solitary patient was lost, even when it had been 
commenced under the most favourable circumstances, 
From these facts, it clearly appeared that the complaint, 
when attacked in the commencement, was generally cura- 
ble, but, when advanced beyond a certain point, almost al- 
ways irremediable. It likewise forcibly struck me, that 
when purgative medicines failed to procure stools in the 
first instance, the disorder commonly gained so much pow- 
er, in the time lost in their repetition, as to become uncon- 
trollable. This naturally led me to give larger doses, that 
the bowels might, if possible, be thoroughly opened at an 
early stage of the disease. Having, however, witnessed 
some cases in which the aperient plan was not singly ade- 
quate to the cure, I was the more satisfied, that both vene- 
section and purging were generally necessary. Thus far 
were my views extended, when the disease, described in 
the beginning of this work, began to attract the*most seri- 
ous attention, from the death of five women in rapid suc- 
cession. In three of these cases the active use of purga- 
tives had been entirely trusted to, with a strictly antiphlo- 
gistic diet, and occasional anodynes. In the other two, 
moderate bleeding was conjoined ; and it was observed, that 
in these the greatest relief had been afforded to the symp- 
toms ; though the purgatives in the other examples had 
always less or more alleviated the abdominal uneasiness, 
when they acted freely in the stage of excitement. Four 
of the fatal cases having occurred in the practise of Mr. 
Gregson, and my opinion having been requested in three of 
them, it may readily be conceived that we felt great anxie- 
ty from such untoward events. On reflection, however^ 
we were sensible, that we had followed the only principle 
of treatment upon which any rational confidence could be 
placed ; and if we had any thing to regret with respect to 
ourselves personally, it was in not having carried this prin- 
ciple of depletion sufficiently far ;n the commencement. 

In fact, every review of these unfortunate cases tended 
more strongly to convince me of the truth of my former 
impression, that bleeding and purging were the most prom- 
ising remedies ; and experience had taught me that even 
these would be inefficient, unless they could be brought to 
operate powerfully together on the disease in its first stage, 



U THE PUERPERAL FEVER. 

Thus prepared, I determined to unite and carry venesec 
tion and purging further than before, if any cases of the 
same kind should again be timely entrusted to my care ; 
and an occasion soon offered itself which enabled me to 
put my determinations into effect, not only without oppo- 
sition, but with the complete concurrence of Mr. Gregson. 
the attendant surgeon, whose opinions were similar to my 
own. 

The patient had not been ill longer than twelve hours ? 
and the case seemed fully as threatening as any of those 
which had ended unfavourably. Twenty-four ounces of 
blood* were immediately drawn from a large orifice so as 
to induce fainting, one scruple of calomel, suspended in 
mucilage, given immediately afterwards, and two ounces 
of a strong infusion of senna, containing two drachms of the 
sulphate magnesia, ordered tol)e taken every hour till copi- 
ous evacuations should be produced. The attendants were 
directed to allow the patient barley water, agreeably acidu- 
lated with lemon juice, for a common drink and diet, and 
to withhold the smallest portion of solid food, or stimulat- 
ing liquids. In about four hours the medicines began to 
operate, and several copious, dark, fetid stools were dis- 
charged ; from that time considerable relief was obtained^ 
and a regular perseverance in purgatives, with mucilagi- 
nous drinks, and a small quantity of exceedingly weak 
chicken broth, completed the cure in five days. Several 
cases of a similar description succeeded, and being treated 
upon similar principles, the result was always equally fa- 
vourable. In some instances, however, it was found that 
more than a scruple of calomel was necessary to act fully 
on the bowels with the desired rapidity, the dose was ac- 
cordingly increased to half a drachm, not only without 
danger, but apparently with decided advantage. When 
the inflammatory symptoms were subdued, small opiate 
draughts or enemata were very useful in allaying the irri- 
tation of the system, and inducing quiet sleep ; but they 
seemed to be prejudicial in the very commencement of 
the fever, before evacuations were employed. 

In addition to bleeding and purging, Mr. Gregson was 
induced, from an accidental circumstance, noticed in hi? 

* Iu all the cases, the blood drawn was covered with a buffy coat. 



THE PUERPERAL FEVER. 4^ 

communication, to prescribe antimonial emetics, and he 
found them to be excellent auxiliaries, never using them, 
however, till the patient had been freely bled or purged* 
Three severe cases which I attended were treated by 
blood-letting, purging, and vomiting, successively employ- 
ed in less than twelve hours, and the united influence of 
these was certainly very striking ; a complete change hav- 
ing been brought about in the state of the circulatory sys- 
tem, and almost every symptom of inflammation and fever 
entirely subdued. Dr. Denman, M. Doulcet, and other 
writers, have borne testimony to the usefulness of emetics 
in the puerperal fever; and, though thinking favourably of 
them myself, when given in the manner above mentioned, 
yet I must confess that bleeding and purging were the two 
remedies, in which my chief confidence was placed in the 
treatment of this epidemic. 

From accurate documents now before me, it appears that 
from the 1st of January to the 1st of October, 1813, forty- 
three very distinctly marked cases of the puerperal fever, 
occurred to five practitioners residing in Sunderland, and 
the adjacent parishes, and only five cases out of the whole 
number terminated fatally. By comparing these results 
with the reports as to the general fatality of the puerperal 
fever, and by examining the evidences contained in the ap- 
pendix, the superior advantages of the practice pursued 
will be fully apparent. 

The thirty-eight successful cases were all treated by a 
system of copious evacuation; and in twenty-nine of them, 
calomel was exhibited either in doses of a scruple or half a 
drachm at the beginning, and occasionally repeated in the 
course of the distemper. For the most part it operated so 
expeditiously, with the other purgatives, that there were 
very few instances in which ptyalism was excited, and wher- 
ever it did occur, it seemed favourable, all of such patients, 
except one, recovering with more than ordinary celerity : 
and to illustrate the superior efficacy of large doses of calo- 
mel further, it may be here remarked, that in none of the 
five fatal cases more than fourteen grains of calomel were 
given on the accession of the fever, jalap, sulphate of mag- 
nesia, and castor oil, being the cathartics chiefly employed 
during its progress. 



46 THE PUERPERAL FEVER. 

To a person in health, or but slightly indisposed, such an 
extraordinary dose as twenty or thirty grains of calomel 
would be followed by unpleasent and violent effects ; but 
when the constitution labours under a febrile disorder of 
the high inflammatory kind, calomel, given to a large 
amount, is not succeeded by disagreeable, but beneficial 
consequences ; a circumstance which shews, that the ope- 
ration of this remedy is materially influenced by the state of 
the system at the time of its administration. Indeed this 
must be apparent at first sight. In health, the violent ope- 
ration of calomel would of itself produce a disease, but in 
fevers, especially in those increased by irritations of the 
primae viag, there is something in the morbid state of the 
system which prevents its distressing effects ; and, as far as 
it does act, it has a direct tendency to diminish the febrile 
commotions ; so that no reasoning from its operation, in 
ordinary cases, can with propriety restrain us from giving 
it with greater freedom in extraordinary cases. 

In some few severe cases, which took place in very 
weak, broken-up women, venesection appeared to be inad- 
missible, and calomel was prescribed, in large quantities 
with the sulphate of magnesia and castor oil ; and though 
the patients finally did well, their recovery was slow and 
doubtful for some time, and they had a strong tendency to 
hectic, long after the abdominal symptoms disappeared. 
Whereas those patients who were copiously bled and purg- 
ed, or bled, purged, and vomited successively, were usually 
convalescent on the fourth or fifth day, and from that time, 
regained their health and strength rapidly. 

My correspondent Mr. Wolfe, whose opinions I greatly 
respect, relies principally upon the daily exhibition of pur- 
gative medicines, and his practice has been generally suc- 
cessful. This may be partly attributed to his discernment, 
and unremitting attention to the duties of his profession ; 
the former enabling him to detect, and the latter to attack 
the disorder when first advancing. But from repeated 
conversations which I have had with Mr. Wolfe, it would 
seem, that the cases which have fallen under his observa- 
tion were divested of the violence of the worst forms, 
which will be found to require a combination of the mosr 
powerful means that have been singly recommended and 
adopted by practitioners of the first authority. This was 



THE PUERPERAL FEVER. 47 

so much the case in the epidemic, which has been made 
the chief subject of these pages, that hardly any patients 
escaped who were not early bled, except those which Mr. 
Wolfe attended, and a few others which had a subdued 
character. It is worthy, too, of particular notice, that the 
disease fell under the observation of some who had received 
an early and a strong prejudice against venesection ; but 
they finally abandoned this prejudice from its being fatal to 
their patients, and became the decided advocates for the 
use of the lancet from direct proofs of its efficacy. Some 
differences, indeed, exist on minor points, among those gen- 
tlemen who honoured me with their correspondence, but 
they all agree in the principle of early and powerful deple- 
tion. This remarkable agreement appears to lay the 
foundation for a fair inference in favour of the inflam- 
matory character of the puerperal fever ; since those who 
have treated it successfully, in whatever else they may 
differ, accord in this, that it can only be overcome by such 
means as are constantly had recourse to for the removal of 
inflammation. In many of the cases which occurred at 
Sunderland, one blood-letting, carried to syncope, and as- 
sisted afterwards by purgatives, sufficed to accomplish the 
cure, but in some a second venesection was requisite ; and 
where it was promptly employed on the continuance or 
recurrence of the urgent symptoms, it was highly advan- 
tageous. The following case, however, will serve to show, 
that even repeated bleeding may be of comparatively little 
benefit when partially adopted in the first instance, and at 
a considerable interval in the second. 

Catharine Bewick, aged nineteen years, unmarried, and 
of a robust habit, was delivered of her first child on the 
23d of August, 1813, after a severe labour. The placenta 
was thrown off about twenty minutes after the birth of the 
child ; and though the discharge had hitherto been trifling, 
in an hour it became so considerable, as to require the ap- 
plication of cold to restrain it. Mr. Tulloch, who attended 
this woman, on visiting her the next day, found that she had 
passed a good night. Her bowels had been freely moved 
from some castor oil, which had been administered before 
her delivery. There was neither pain nor tension over 
the abdomen, and she had passed her urine (ree\y without 
the least uneasiness. 



48 THE PUERPERAL FEVER. 

Mr. Tulloch being unavoidably called to a distance early 
on the morning of the 25th, he requested a professional 
friend to pay her a visit in the course of the day. On his 
return in the evening, he learned from his friend, that at 
midnight on the 24th, the patient had been seized with a 
strong rigor, which lasted for some time, and which was 
followed by a hot fit, and all the usual symptoms of the 
puerperal fever. The disease had existed about ten hours 
when this gentleman was called to attend for Mr. Tulloch, 
and he immediately drew about twelve ounces of blood 
from the arm, enjoined a strictly antiphlogistic regimen, and 
prescribed ten grains of calomel to be taken immediately, 
and four table spoonfuls of an infusion of senna, with salts, 
every two hours afterwards, until the bowels should be 
freely moved. 

At six o'clock in the evening another visit was made, two 
very small stools had been procured, the abdomen was 
still tense, and very painful on the slightest pressure, and 
the pulse 130 in the minute. 

From the urgency of the symptoms, this gentleman was 
then induced to draw sixteen ounces of blood, and to di- 
rect a continuance of the purgative mixture. Mr. Tulloch 
having returned from his journey at nine o'clock, he im- 
mediately visited the patient with his friend, and they were 
both disappointed to find that the purgatives previously 
taken had failed to procure free evacuations, the pulse had 
risen to 160, and the anxiety, restlessness, heat, pain and 
tension of the belly, were all increased. 

At this period,, my assistance was first requested, and it 
wcs agreed in consultation, that half a drachm of calomel, 
in an ounce of the mucilage of gum arabic, should be di- 
rectly given, and the dose of the mixture repeated every 
hour. At midnight another visit was paid. The patient 
h'c>d passed several large stools, the pulse was now 140, the 
pain and tension of the belly were greatly relieved, and 
the anxiety, thirst, and restlessness, considerably diminish- 
ed. The mixture was ordered to be continued as before. 

As one stool had only been procured by five o'clock in 
the morning of the 26th, ten grains more of calomel were 
given in a bolus, and the mixture repeated. Two hours 
afterwards, she had two copious stools of the appearance 
of gruel. The pulse was then 120, the tenderness, pain. 



THE PUERPERAL FEVER. 49 

and tension of the belly diminished, the countenance less 
anxious, the tongue cleaner and moister, and the thirst not 
so urgent. By continuing the mixture, three additional 
stools were procured before noon, when it was omitted, 
and one prescribed containing three ounces of castor oil, 
with nine of mint water, of which four table spoonfuls were 
directed to be taken every two hours. At nine o'clock in 
the evening the bowels had been three times copiously 
moved from the castor oil, on which account it was not re- 
peated ; but by way of lessening the force of the circula- 
tion, the third of a grain of tartarized antimony was ordered 
every two hours, and thirty drops of the tincture of opium 
were given at bed-time, to allay irritation. On the morn- 
ing of the 27th, it was found, that she had obtained but 
little sleep, and no evacuation by the bowels. There was 
some slight increase of fever, probably arising from these 
two circumstances. Two ounces of the sulphate of mag- 
nesia, with one grain of tartarized antimony, and nine oun- 
ces of the infusion of senna, were prescribed as a mixture, 
four table spoonfuls of which were administered every two 
hours during the day. At eight o'clock in the evening it 
was reported, that she had had three very plentiful stools, 
and that the pain and tension of the belly were nearly gone, 
though the former was still increased by pressure. The 
pulse remained at 120, but the anxiety, heat, and thirst, 
were all considerably abated. The anodyne was repeated 
at bed-time, and a mucilaginous drink slightly acidulated 
ordered to be taken occasionally, in a little barley water. 
She passed a good nighty the pulse the next morning was 
still 120, and the other symptoms as before. Weak chick- 
en broth was now allowed. Castor oil was again prescrib- 
ed ; and in the course of the day she took so much as three 
ounces, which purged her five times; but the stools had 
now a natural appearance, and though the skin was hotter 
than natural, yet it was perspiring freely. The pulse still 
continued at 120, and slight pain was felt on pressure over 
the belly. The anodyne was repeated at bed-time, and 
moderate doses of the liquor ammon. acet. ordered during 
the night at intervals of two hours, in order to keep up 
the perspiration. She got no sleep, and at ten o'clock on 
the morning of the 29th, she complained much of pain 
nearlv in the situation of the right lateral ligament of the 

8 



50 THE PUERPERAL FEVER. 

uterus. The skin was very hot, though she still perspired 
iYeely, and the pulse had risen to 130, and was rather hard. 
One scanty stool had been passed with some griping pain, 
and the anxiety, restlessness, and thirst, were much aug- 
mented. The sudorific mixture was omitted, and ninety 
drops of the tincture of opium prescribed, under the form 
of a small enema, that it might be retained in the rectum* 
She was rather easier from the injection, but at noon the 
abdominal tenderness, tension, and pain, had returned, the 
last of which was increased by the slightest pressure. The 
pulse continued at 130, the tongue was dry, the thirst in- 
tense, the countenance pale and dejected, the skin very 
hot, but moist; and these symptoms were accompanied 
with aching of the temples, and impatience of light and 
noise. As it was conceived that the chicken broth might 
possibly have been made stronger than was directed, or 
that at all events it might have increased the excitement, 
it was omitted, and gruel, with a little milk, substituted. 
Four table spoonfuls of the mixture, containing two ounces 
of the sulphate of magnesia, were ordered to be taken 
every half hour, until the bowels should be freely opened. 
At nine in the evening all the mixture had been taken, but 
without effect ; and the pulse was then 135, the restlessness 
great, the thirst intense, the countenance extremely anx- 
ious, the respiration short and quick, and the rest of the 
symptoms the same as at the morning visit. An ounce and 
a half of castor oil was given in a little warm coffee ; but 
two hours afterwards no evacuation by the bowels had 
followed, the pulse had risen to 140, and it was small and 
compressible. In other respects there was no material 
change. Warm fomentations were ordered to the abdo- 
men, a common purgative enema administered, and a scru- 
ple of calomel given in the mucilage of gum-arabic. 

She was visited at seven o'clock on the morning of the 
30th, and the medicines had occasioned five very copious 
stools of a much darker colour than before. From these 
evacuations, she had experienced great relief, the pulse had 
come down to 120 in the minute, the heat of the surface 
was lessened, the tongue moister, the countenance more 
composed, but the pain of the right side was still severe 
especially when she moved, or when pressure was applied! 
Slight ptyalism was now observed for the first time. In the 



THE PUERPERAL FEVER m 

course of the day she took, in divided doses, five drachms 
of a powder composed of equal parts of jalap, and the sup- 
ertartrate of potass, from which she procured three evacua- 
tions by six o'clock in the evening, when the anodyne ene- 
ma was again ordered, on account of the continuance of the 
abdominal pain and general irritation. But as this had 
procured no sleep, as the pulse was still above 130, and as 
the other symptoms remained unaltered, at ten o'clock the 
spme evening, a mixture was prescribed, containing two 
ounces of the sulphate of magnesia, eight of mint water, 
two scruples of jaiap, and two grains of tartarized antimo- 
ny. But under an impression, that she might possibly still 
obtain some rest, it was directed not to be exhibited till 
two o'clock on the ensuing morning ; .when three table 
spoonfuls were to be given, if awake, and repeated every 
two hours afterwards. She had several hours of sleep in 
the night, and at eight o'clock a. m. of the 31st, she was 
rather more composed ; the heat and thirst- being less ur- 
gent, and the pulse six beats less in the minute. As only a 
part of the mixture had been taken, it produced no evacua- 
tion, and even the whole of the remainder was ineffectually 
administered ; so that at noon one ounce and a half of cas- 
tor oil was given, which occasioned four dark-coloured stools 
by eight o'clock in the evening, when the pulse was 125, 
and the other symptoms as before. Twelve grains of the 
compound powder of ipecacuan were ordered at bed-time, 
with a view of allaying uneasiness, and exciting perspira- 
tion. 

She had but little sleep, and on the next morning, the 1st of 
September, there was no material change in her condition. 
The anodyne enema, was once more had recourse to, and 
four of the colocynth pills with aloes were directed to be 
taken every six hours. But at eight o'clock in the evening 
the bowels had not been opened, and the pulse was then 
130, the heat of the surface considerable, the countenance 
extremely anxious, and much pain on pressure over the ab- 
domen. The cathartic pills were omitted, and a drachm of 
the compound powder of jalap prescribed immediately, and 
half a drachm was ordered to be exhibited every two hours 
afterwards, until the bowels should be moved freely. Hav- 
ing taken two drachms and a half of this medicine, she had 
four copious and feculent stools, after which she slept about 



o4 THE PUERPERAL FEVER, 

three hours. At nine o'clock in the evening, the pulse was 
125, without any other alteration of consequence in the 
symptoms ; but as she appeared to be much exhausted, 
beef-tea, chicken broth, and milk, were allowed to be given 
freely. At eight o'clock in the evening, it was reported that 
she had had no stools since the morning. The pulse was 
130, the tongue dry, the thirst great, the heat, restlessness, 
and anxiety considerably increased ; while a general tume- 
faction and pain existed over the belly, accompanied with 
much confusion of thought, and a more urgent uneasiness in 
the head. An ounce and a half of castor oil was immedi- 
ately given in warm coffee. After having had four evacua- 
tions, she obtained some disturbed sleep. But at an early 
hour on the 3d, the pulse was 140, the countenance pale 
anxious, land dejected, the tongue dry, the thirst urgent, and 
the perspirations were profuse, without at all reducing the 
heat of the skin. The respiration, too, had become short 
and wheezing, and considerable enlargement, with tension 
and tenderness, had taken place over the abdomen, which 
felt as if an effusion had taken place into its cavity. As the 
chicken broth seemed formerly to have augmented the ex- 
citement, it now appeared, as highly probable, to have pro- 
duced a similar effect, aided by the beef-tea; and on this 
account they were both ordered to be immediately omit- 
ted, and gruel, with a little milk, was directed instead. 

As the case now seemed all but hopeless, and as active 
purging had before given decided relief for a time, it was 
resolved once more to try the full influence of this plan. 
Twenty-four grains of calomel were therefore given in an 
ounce of mucilage, and four table-spoonfuls of a mixture, 
composed of two ounces and a half of sulphate of magne- 
sia, and eleven of the tartarized infusion of senna, were or- 
dered every four hours, till the bowels should be plentifully 
evacuated. At the evening visit, it was found that the pa- 
tient had procured five very copious stools, which contain- 
ed, to our surprise, many small pieces of dark-coloured 
scybala, which had probably been retained for some time. 
The pulse was now only 125 ; the heat, thirst, restlessness, 
and anxiety were all greatly relieved ; and the swelling 
and pain of the abdomen considerably less. Four table- 
spoonfuls of the purgative mixture were ordered to be ta- 
ken every two hours during the night, if the patient should 



THE PUERPERAL FEVER. 

be awake. Soda-water was recommended for the common 
drink. She had a sleepless night, owing to the frequent 
operation of the purgative medicine. But on the morning 
of the 4th, the pulse had fallen to 120, the countenance was 
less depressed, and the swelling and tenderness of the bel- 
ly were quite gone. Still some wheezing existed, but 
without pain or tightness of the chest, so that it seemed 
to be purely bronchial. The tongue was cleaner, not- 
withstanding the thirst ; and dark copious stools had been 
procured, with flocculi of a whitish appearance floating on 
the surface. The purging mixture was discontinued ; but 
three additional evacuations occurred before the evening, 
from the doses previously taken. On account of the 
wheezing being rather more troublesome, and the pulse 
somewhat quicker, half a grain of opium was given at bed- 
time, and a similar dose ordered to be repeated in four 
hours, if sleep should not be obtained. Besides, a pecto- 
ral mixture was prescribed, chiefly composed of the vine- 
gar of squills, with the common mucilage, and a very small 
portion of laudanum. About this time, the abdominal 
were completely lost in the pectoral symptoms, which con- 
tinued till the 6th of September, when a blister was appli- 
ed to the chest, which gave great relief. From this pe- 
riod she recovered apace ; and in about a month afterwards 
returned to her ordinary employment of a menial servant. 
This interesting history is only a narration from the notes, 
which were most carefully taken by Mr. Tulloch,* whose 
great attention, skill, and kindness so largely contributed 
to the recovery of the patient. 

If this case had been treated more actively by the gen- 
tleman who was first consulted, it is highly probable, as he 
himself afterwards thought, that it would have been speedi- 
ly cut short; and if it were possible that I could be again 
called in under precisely the same circumstances, I would 
employ venesection decisively, though the lancet had been 
twice previously used ; for the strength of the patient was 
then not only unsubdued, but the inflammation in the ab- 
domen existed in full force, and therefore bleeding should 
not have been withheld. The extreme nervous irritation 
which existed was the reason why blisters were not em- 
ployed after she came under my care ; but it is not unlike- 

* Now furgeon in Newcastle-upon-Tyne. 



m THE PUERPERAL FEVER« 

iy that local blood-letting might have been advantageous, 
an application which I would not now omit in an instance 
of the same kind. As for the rest of the treatment, it may 
be remarked generally, that I prescribed too much medi- 
cine ; so that if the case were to be treated over again, I 
should keep an action on the bowels by less complicated 
means. Two errors were committed in the diet, for it was 
evident, that she became worse each time after the exhi- 
bition of the animal broths, which sometimes., even when 
weak, stimulate the heart more than might be ti priori ex- 
pected ; and it may be regarded as a general rule, that the 
regimen ought to be strictly antiphlogistic till the inflam- 
matory symptoms be subdued, and therefore the dieta aquea 
is undoubtedly the best. Sometimes after copious deple- 
tion, when there is much acidity and flatulence of the 
stomach, with a consequent irritability of that organ, ex- 
ceedingly weak chicken broth appears to be useful : but 
then the greatest attention should be paid by the practi- 
tioner, to see that it be made exceedingly weak and sparing- 
ly administered, otherwise a most hazardous mistake may 
be committed by the attendants of the sick ; and even when 
convalescence is induced, an abstemious diet must be scru- 
pulously enforced, since to deviations in this respect, re- 
lapses of fever may very often be distinctly referred. It is 
a great weakness in a medical man to give way to the wishes 
of patients respecting their regimen ; for he should consider 
what is most proper for them, and having fixed upon that, 
he ought to be unbending in his determination. In the young 
woman, whose case has been detailed, the fever was kept 
up by considerable anxiety of mind, under which she la- 
boured from the loss of her moral character. Added to 
this, she lived in a small ceiled garret in a noisy situation, 
and had a presentiment that she should certainly die ; a 
presentiment which is always unfavourable, and sometimes 
fatal, especially in the affections of child-bed ; so that if 
these, with some circumstances in her treatment, be taken 
into the account, her recovery may be deemed somewhat 
remarkable. The following case where the lancet was on- 
ly twice called for, may serve to show how much depends 
upon the manner and time in which it is employed. 

Mrs. R. a stout and healthy young woman, in the 28th 
year of her age, was delivered on the 2d of the month. 
She had a natural and easy labour, and seemed to be re- 



THE PUERPERAL FEVER. 55 

covering extremely well, till very early on the morning of 
the 4th, when she was seized with shivering speedily fol- 
lowed by head-ache, nausea, and retching. At noon of 
the same day, about ten hours after she felt first indispo- 
sed, I was requested to visit her ; the pulse was then as 
high as 134 in the minute, the skin pungentiy hot, the 
tongue white and dry, the milk and lochia almost entirely 
suppressed, the urine passed with some uneasiness, the 
breathing much quickened, the abdomen tense, and so sore 
that the weight of the bed-clothes could not be borne upon 
it. Her countenance was very anxious, and she complain- 
ed of great oppression, pain, and weak .ess. 

Twenty-four ounces of blood were drawn immediately 
from the arm, and she fainted. A scruple of calomel, mix- 
ed in mucilage, was given directly after venesection, and 
two drachms of the sulphate of magnesia, with an ounce 
and a half of the infusion of roses, ordered to be taken eve- 
ry hour till five or six copious stools should be procured. 
Barley water, with a little isinglass in it, was allowed as a 
common drink and diet. When she was again visited at 
six o'clock in the evening, it was found that the blood ab- 
stracted had a firm crassamentum, which was cupped and 
sizy. The patient had passed only three scanty, fetid evac- 
uations, and did not appear to be much relieved, the symp- 
toms being then nearly as urgent as at the last visit. 
Twelve ounces of blood were taken away immediately, 
which again made her feint. Twenty grains of calomel 
were prescribed, and a mixture, composed of an ounce 
and a half the sulphate of magnesia, and six ounces of a 
weak infusion of roses, two table spoonfuls of which were 
directed to be taken every hour, after the exhibition of the 
calomel, till the bowels should be frequently and plentiful- 
ly opened. 

She was visited at six o'clock the next morning. The 
blood drawn last evening was covered with a buffy coat. 
The whole of the medicine had been taken, which pro- 
duced seven large, dark loose stools. The patient was 
very considerably better ; her belly felt soft, and she could 
bear pressure with very little inconvenience. The skin 
was warm and moist, and the pulse reduced to 100 in the 
minute. An anodyne enema, containing a 120 drops of the 
tincture of opium, was directed to be injected immediately. 



m THE PUERPERAL FEVER. 

and the common neutral mixture to be taken in the course 
of the day, with a very little weak chicken broth now and 
then. Several hours of sleep were procured by the anodyne 
enema, and from that time the patient might be considered 
convalescent, but her bowels required to be kept open by 
castor oil, for five or six days longer. 

In the first obscure stage in which the puerperal fever is 
ushered m by paleness of the surface and oppression, or by a 
pretty distinct attack of rigor, the animal heat is almost al- 
ways below the natural standard ; and it is of great conse- 
quence towards lessening the degree of the subsequent ex- 
citement, that the natural temperature of the surface should 
be as rapidiy restored as possible. When a tepid bath, there- 
fore, can be speedily obtained, it frequently has an excellent 
effect, if it can be used without fatiguing the patient ; and 
where that cannot be speedily had, the blandest tepid 
drinks must be recommended, and warm bottles of water 
put to the feet and stomach, which are good substitutes for 
restoring the circulation of the surface, and relieving the 
internal organs from an over pressure of blood. An enema 
should first be ordered, and a dose of castor oil afterwards 
by way of more effectually clearing the bowels. All kinds 
of diffusible stimuli ought to be expressly prohibited at this 
period, for they are extremely pernicious. The animal 
heat having been restored, and the character of the disease 
developed, not an instant of time ought to be lost in at- 
tempting to arrest it : and even in those cases where some 
doubt may exist respecting the actual presence of inflam- 
mation, it is better as a general rule, to bleed at once ; for 
by trusting to a purgative, or to some other secondary 
measure, the patient may thereby be lost from the delay, 
and even in ordinary fever occurring in child bed, no harm 
can result from early and moderate venesection. In the 
excellent letter with which Dr. Joseph Clarke of Dublin 
has honoured me, he has inculcated a doctrine in some re- 
spects different from this, in suspicous cases ; but so fixed, 
by experience, is my conviction of the utility of blood-let- 
ting, whenever there is a marked tendency to fever in child- 
bed, that it becomes an imperative duty in me to enforce 
it without the least reservation. 

In acute diseases, it has been too much the practice to 
confide in one principal measure, but in general they may 



THE PUERPERAL FEVER. 57 

be best removed by a series of antiphlogistic measures. 
Although strenuously insisting upon the utility of venesec- 
tion at an early period in the stage of excitement, yet it was 
never my intention to affirm, that it is of itself generally 
equal to the removal of the puerperal fever. On the con- 
trary, it has commonly failed in my hands unless followed 
by free purgation ; and on inquiry, too, I find, that the 
patients of those authors who adopted venesection gene* 
rally died, when the purgatives did not act at all, or only 
imperfectly. It is not, then, simply bleeding and purging 
in which I have so much confidence, but in copious bleed- 
ing, immediately succeeded by copious purging, or rather 
in the powers of these two means simultaneously exerted on 
the disease at the onset. 

It has already been noticedthat the puerperal fever often 
remits at the beginning of the second, and at the end of the 
third day, and, as such a calm is often the prelude of another 
and more serious attack, laxatives should rarely be inter- 
mitted till after the third day. The quantities of excrement 
discharged in the course of this complaint are frequently 
so very great that nurses, and even patients themselves, 
often strenuously oppose a regular perseverance in the use 
of laxatives, conceiving that such extraordinary evacuations 
can neither be necessary nor useful ; but appeals of this 
nature must never turn the parctitioner irorn his purpose, 
and so long as there are pain and tension of the abdomen, 
a quick pulse, aud offensive stools, he must steadily pro- 
ceed, unsubdued by remonstrances, however urgently 
made. 

When the stomach/as occasionally happens, is so exces- 
sively affected in commencement, that almost every thing 
taken is immediately rejected, the case may be considered 
violent, and it strongly indicates the necessity of liberal 
blood-letting, which at once tends to lessen the disorder, 
and to allay the irritability of the stomach. Immediately 
after bleeding, however, a large cathartic enema should be 
administered, as evacuating the lower part of the intestines 
is favourable towards the retention of the purgatives after- 
wards exhibited ; and in such examples calomel in mucilage 
will be more likely to be retained than any other, especially 
if combined with a little opium, which does not tend to 
constipate in inflammatory affections of the abdomen, as I 

9 



oz THE PUERPERAL FEVER. 

have witnessed in numerous cases* The bowels having 
been completely opened, the sickness will most frequently 
abate ; but if it should not, it is a sign of some visceral 
mischief, which demands the prompt use of the. lancet. 

When the pain is very severe, flannels, wrung out of hot 
water, applied to the belly, as warm as the patient can 
bear them, sometimes afford considerable though brief re- 
lief; and, being satisfied with their effects, I have never 
ventured to try cold applications, notwithstanding they 
have been favourably reported by a very judicous physi- 
cian.* But I must here observe, once for all, that fomen- 
tations, and every species of topical application, are only 
secondary means at the best, and ought not for a moment to 
make the practitioner lose sight of the main part of the 
treatment, viz. copious venesection, and early, active, and 
repeated purging. 

When the fever is known or supposed to be contagious, 
many practitioners object to the bare proposal of general 
depletion, and especially when such an affection attacks a 
woman in child-bed, the exhaustion induced by delivery, 
and the additional debility supposed to be the consequence 
of contagion, strongly inclining them to adopt the gentlest 
measures. But, if we consider, that there is a great change 
produced upon the system, by the return into the circula- 
tion of a portion of the blood which supported the foetus, 
that the weakness succeeding parturition, so far from pre- 
venting, is the very state in which phlogistic diseases most 
readily take place ; and above all, that the puerperal fever 
is invariably attended by an active abdominal inflammation, 
no fears about debility and contagion should deter us from 
depletion, the only remedy in this formidable malady. It 
is not, however, in the partial adoption of the means re- 
commended, that success will be found. Small bleedings 
and partial purging may weaken the patient, but will not 
remove the disease ; whereas free bleeding and active 
purging will subdue the disease, and leave nothing but mere 
debility to be counteracted. 

It is not possible to fix, with propriety, the quantity of 
blood that should always be drawn in the puerperal fever, 
for that must vary according to the effects produced ; and 
it may always be held as a practical rule of the first im- 

* See a Taper by Thomas Sutton, M. D. in No. XXXV. p. 318, of the 
Edinburgh Medical and Sunrical JonrnaJ. 



THE PUERPERAL FEVER. 59 

portance in blood-letting, that it is the effect produced, and 
not the quantity drawn, which should regulate us in its em- 
ployment. The great object of bleeding in the puerperal 
fever, and the remark may be extended to other inflammato- 
ry affections, is to arrest the general excitement, and the 
topical inflammation ; and of the arrestation of the former 
we judge by the decline of the fever, and of the latter by 
the cessation of pain. So long, therefore, as the stage of 
excitement exists, combinedly with local pain, so long may 
the use of the lancet be indicated ; but if one bleeding 
checked both, it would be manifestly absurd to proceed 
further, and to stop short where it did not give relief, would 
be a weakness that might be followed by fatal consequences. 
When bleeding subdues the pain, and the pulse notwith- 
standing continues to be quick and the fever urgent, some 
latent inflammation may almost always be apprehended, 
and in such cases a repetition of the lancet will commonly 
be necessary ; for unless the increased action of the heart, 
and the increased heat be removed, some deep visceral 
disorganization will mostly be effected, from the mere con- 
tinuance of the general excitement. 

In certain patients, one early and decisive bleeding will 
be found quite sufficient, with the aid of purgatives ; in 
others two may be required, and there are some, where 
the operation must be even oftener repeated. In first 
venturing upon the depletory practice, 1 rarely durst go 
beyond one blood-letting, but finding that sometimes fail, a 
second was tried from a sort of necessity, and thus expe- 
rience gradually led me to pursue the mean till the end for 
which it was adopted should be answered. To confirm by 
actual facts how much bleeding requires to be varied, it 
may be observed that in the epidemic which occurred in 
the North of England, one very timely and very free 
bleeding was all that was required in many instances, when 
followed up by active purging; but cases occurred which 
could not be removed without a second, though beyond 
this the operation was rarely necessary, .so far as my in- 
quiries have extended. Since then, however, I have met 
with some epidemic and sporadic cases where little or no 
alleviation of the urgent symptoms took place till the third 
blood-letting, and in a few the operation was more fre- 
quently necessary. It would appear in what has been cal- 
led the hospital puerperal fever, which authors have deem- 



1 



60 THE PUERPERAL FEVER. -. 

ed the most typhoid and malignant form of the disease, 
that as active a treatment is demanded as in any other 
modification-, at least I shall now adduce some cases, and 
some communicated facts which may show how much that 
complaint is under the influence of depletion in the com- 
mencement. 

Through the kindness of my friend Dr. Davis, to whom 
I am peculiarly indebted, the Managers requested me to 
attend a Public Institution, where the puerperal fever had 
appeared, in the absence of the medical officers upon 
whom the duty more particularly devolved. In entering 
upon this office 1 found one patient convalescent, and 
another labouring under the disease rather urgently ; but 
as both cases were interesting, it may not be useless to de- 
tail them, before those which afterwards happened. 

Early on the 3d of October, 1818,, Elizabeth Serjeant, 
a single woman, aged 22 years, was delivered of her first 
child. The labour lasted nine hours, and produced much 
apparent suffering. Her temper was particularly irrita- 
ble, and about eleven o'clock at night the pulse was 1 10 in 
the minute ; but though several smart rigors had previous- 
ly occurred, she made no complaint, except of abdominal 
tenderness on pressure. At three the next morning, how- 
ever, she had pain in the belly, which was continual from 
that time ; and at eight, the pulse was 100 and strong, the 
skin moist, the tongue whitish and moist, the thirst great, 
the lochia perhaps rather sparing, and much pain existed 
on pressure in the abdomen, particularly in the hypogas- 
trium, attended with swelling and tension of the umbilical 
region. About thirty ounces of blood were drawn when 
it ceased to flow, and her lips became pale, yet she would 
not allow that the pain was much relieved. Five grains 
of calomel, with eight of the extract ofcolocynth. were ad- 
ministered, and as these had not operated at noon, about 
an ounce of castor oil was exhibited. At three o'clock in 
the afternoon no stool had occurred, and there was exqui- 
site tenderness on pressure of the abdomen, especially of 
the right i Iliac region. The pulse was then 108, the tongue 
moist, and the skin hot and dry. The common cathartic 
enema was immediately injected, a large blister applied 
over the abdomen, and eighteen grains of the blue mercu- 
rial pill, with half a drachm of the compound powder of 



THE PUERPERAL FEVER. 61 

ipecacuan, were made into six pills, one of which was or- 
dered every fourth hour, with a little of a sudorific mix- 
ture. By ten o'clock that night, the bowels had been ve- 
ry freely opened, and there was then no abdominal pain 
whatever; but she had displayed much irritation of tem- 
per, and used even violence to the nurse. The tongue 
and skin were both moist, and the pulse was about 136 in 
the minute. 

On the 5th no pain existed, and she had slept tolerably. 
The tongue was moist, the skin dry, the pulse 120. and 
the belly much swollen. The blister had done its office 
well, the milk and lochia were secreted, and the bowels 
had only been once opened. She had saline arid sudorific 
medicines, and castor oil when necessary, till the 7th. 
when she complained of general head-ache, and on the 
8th, she became decidedly maniacal. The lochia continu- 
ed to flow, but the milk was diminished. There was now 
neither pain of the head nor of the belly. The strait 
waistcoat was put on, a cold lotion applied to the head, 
and repeatedly small doses of the sulphate of magnesia 
given, in order to move the bowels. She slept well, and 
on the morning of the 10th the face was suffused with an 
erysipelas, which had been gradually increasing for about 
two days previously. Two scruples of the cinchona were 
ordered every three hours, with a diet of broth, bread and 
milk. The bowels continued very open under the use of 
the cinchona, the erysipelas began to subside on the 12th, 
and by the 15th the mind was perfectly distinct. In less 
than a month from her delivery she was enabled to leave 
the Institution quite well. The two most remarkable cir- 
cumstances in this case were, the great relief which free 
purging afforded after a very copious venesection, and the 
apparent translation of disease afterwards, first to the head, 
and then to the face. It is well known, that erysipelas 
and the puerperal fever often prevail at the same time ; 
whenever this happens, more than ordinary attention should 
be paid even after the subsidence of both ; .and perhaps 
one of the best modes of guarding against visceral attacks 
of erysipelas, is to blister the surface, which was according- 
ly done towards the close of this case. 

Martha Besant, a married woman, aged 25 years, was 
delivered of her second child on the 1st of October. On 



m THE PUERPERAL FEVER. 

the night of the 9th she was attacked by fever, and bear- 
ing down pain in the hypogastrium. The pain soon left 
her, but was reported shortly to have returned. She took 
nearly an ounce of castor oil, some infusion of senna with 
the sulphate of magnesia afterwards, was fomented over the 
abdomen, and obtained ease, sleep, and one evacuation by 
the bowels. About nine o'clock, however, on the morn- 
ing of the 1.0th, the pulse was 1 1 1 in the minute, accompa- 
nied with pain and distension of the abdomen. The tongue 
and skin were moist, and the lochia as well as the milk se- 
creted. Venesection was now employed till it nearly pro- 
duced fainting. Three hours afterwards the pulse was re- 
duced to 96, the skin was cool and moist, and three fetid, 
greenish stools had been passed ; but still some pain of the 
belly existed on a moderate inspiration. One grain of opi- 
um with a saline draught, was ordered every sixth hour. 
About bed-time, she was attacked by most acute abdomi- 
nal pain, bled as liberally as before, and took two grains of 
opium during the night. The next morning at eight, some 
pain still remained on deep inspiration, for which foment- 
ations were used. The pulse was 102, the skin moist, the 
tongue dry, the milk suppressed, and the belly bound. At 
two o'clock in the afternoon the pulse had risen to 120, 
and there was exquisite pain of the abdomen, though she 
could extend her limbs without increasing it, which mostly 
cannot be done, particularly if the limbs be suddenly ex- 
tended down. It was at this period that my attendance 
upon the Establishment commenced. 

Though the disease had existed so many hours, and 
though the patient had been twice copiously bled, yet the 
urgency of the symptoms seemed still to require the lancet; 
and she was therefore bled again till she fainted, about six- 
teen ounces of blood having been drawn, which was very 
buffed. This operation softened and reduced the pulse to 
104, and moistened the tongue and skin ; and it may be ob- 
served, in passing, that blood-letting will often make a dry 
tongue and skin immediately moist, especially when it in- 
duces faintness. The patient was ordered a cathartic enema, 
ten grains of calomel, and repeated doses of an infusion of 
senna with the sulphate of magnesia, till she should be free- 
ly purged. But as some pain remained, she was again 
bled an hour after to about six ounces, which rendered her 



THE PUERPERAL FEVER, 63 

faint and did not entirely remove the pain. The pulse 
was 112, before and after the operation, and it was found 
still the same at ten o'clock in the evening, when the tongue 
was clean and moist, the countenance good, the skin warm 
and moist, and she complained of no pain whatever. Yet 
she had rather a watchful night, and on the morning of the 
12th slight pain existed on pressure near the umbilicus, and 
the eyes felt sore, without any degree of ophthalmia. The 
lochia had ceased, but some milk was secreted, and many 
fetid, light yellow, oily evacuations had been passed. The 
pulse was 104, the tongue and skin dry, and she had much 
thirst. One grain of opium was now ordered, with the ex- 
pectation, that it might excite perspiration, and allay irrita- 
tion. The pain in the abdomen returning, with increased 
and general uneasiness, she was bled to faintness, at eight 
o'clock in the evening, and the blood drawn buffed rapidly. 
She twice or thrice vomited apparently bilious matter. Af- 
ter venesection she said, that " she had still a catch at the 
navel," on taking a deep inspiration. The lochia return- 
ed, and a commencing erysipelas was observed on the face. 
One grain of opium was exhibited. An hour after the 
operation, there was such decided abdominal distension, 
with uneasiness on pressure, that I was induced to or- 
der vensection once more, but only a trivial quantity of 
blood could be drawn, which was however still buffed, 
though not cupped. Twelve grains of calomel with one of 
opium were given, and castor oil directed to be repeated 
afterwards, till the belly should be most freely evacuated. 
At eight o'clock the next morning there was no pain, but 
still distension of the belly, and the medicine had occa- 
sioned many stools, which were of a light yellow colour. 
The pulse was 95, while the respirations were only eight or 
nine in the minute*, a loss of relation, , however, on the 
right side in such a case, as it at least showed the absence 
of irritation, which quickens the breathing. The tongue 
was very dry, but the skin moist, and therefore it might be 
presumed that the dryness of the tongue had been produc- 
ed by the purging; an effect of purgative medicines more 
common than many authors have imagined in febrile dis- 
eases. At ten o'clock in the evening the tongue was moist 
about the edges, and the skin remained as in the morning. 
The pulse was 90, and the respirations were 22 in the min 



04 THE PUERPERAL FEVER. 

ute, nearly a natural relation. To use her own expression, 
however, the patient had a twitch near the umbilicus. 
Three grains of calomel, two of camphor, and one of opium 
were prescribed in piils, a blister applied to the epigastri- 
um, and castor oil directed to be taken early in the morning. 
At eight o'clock the next morning, the pulse was only 86, 
at one it was 99, and the respirations were 14 in a minute. 
She had then had one stool, there was neither pain nor dis- 
tension of the belly, and the general expression was good. 
The pills of calomel, camphor, and opium were repeated 
at bed-time, and the castor oil ordered for the next day as 
before. She slept pretty well in the night, and on the 15th, 
the pulse was 94, and the respirations 12 in the minute ; 
but though no abdominal pain existed, and the bowels were 
free, a blister was applied to the sternum, in order to guard 
against a translation of the erysipelas which still remained 
on the face. She again slept at night, and in the morning of 
the 16th had no abdominal pain, but the erysipelas was very 
painful, the pulse 1 1 8, and the tongue very dry. Castor oil 
was ordered to be repeated until the bowels should be most 
copiously moved. She continued to go on pretty well 
under the use of the aperient, but on the 19th she had a 
pain in the diaphragmatic region, for which a blister wag 
prescribed, and an anodyne with a sudorific draught. She 
slept well in the following night, and the next morning re- 
ported herself free from pain, refreshed, and at ease. 
Soon after this period, she was most decidedly convalescent 
from the fever ; but she was attacked with that inflamma- 
tory disease, called the phlegmasia dolens, which yielded 
to lacal bleeding by leeches, and to purgative medicines. 
After the removal of this affection, however, she had a 
profound prostration of strength for some days ; yet on the 
21st of November, she was discharged from the hospital 
cured and able to walk. 

This patient was bled four times pretty copiously, and 
twice scantily, during the existence of the puerperal fe- 
ver; so that in all she probably lost nearly eighty ounces 
of blood, before the abdominal inflammation was completely 
subdued. Those cases of the hospital puerperal fever 
which are upon record would seem to indicate clearly that 
if there be any difference between it and the ordinary form, 
Hie difference consists in the greater intensity of the for- 



THE PUERPERAL FEVER, 65 

rner; and it was this which determined me, as the patients 
were young, to pursue depletion until a marked relief 
should be obtained, being confident that half measures 
would only waste the strength without arresting the disease. 
Yet the following case will show, that the most active treat- 
ment will sometimes fail, particularly where a few hours 
are lost in the beginning, and where an organic affection 
happens to be complicated with the fever. 

A. R. a married woman aged 26 years, was delivered 
of her second child on the 13th of October, about ten 
o'clock at night. During her pregnancy she had pain in 
her right flank and back. At eight o'clock on the evening 
of the 14th, the pain of the flank became more acute, and 
the pulse much quicker, being then 150, and perfectly dis- 
tinct. Her bowels had been freely opened on the previous 
day by about an ounce of castor oil, and as she was then 
in a most profuse perspiration, it struck me, that a full ano- 
dyne might alleviate the pain, promote the perspiration, 
and thus carry off the excitement under which she labour- 
ed. But at seven o'clock the next morning, the pulse re- 
mained so high as J 48, the pain was more diffused, the 
tongue very dry, and she had obtained no sleep from the 
opiate. About twenty-four ounces of blood were drawn, 
the crassamentum of which was much buffed ; but no re- 
lief followed, and the tongue remained as dry as before, a 
circumstance which seemed to mark an unusual severity of 
attack. Three hours afterwards she was again bled ad 
deliqmum, and about the same quantity of blood abstracted 
as before, which however was less buffed. The tongue 
became moistened from this venesection, yet the pain was 
not totally removed. A cathartic enema was immediately 
injected, one scruple of calomel with three grains of opium 
exntbited, and an aperient mixture of senna and salts was 
directed to be frequently repeated, till it should act hberaliy 
on the bowels. As the abdominal symptoms were still 
urgent, she was bled to about twelve ounces, live hours after 
the second operation, and twenty-four leeches were applied 
to the abdomen, and a blister to the epigastrium. About 
ten o'clock at night, the pain had not quite subsided, but 
she bore pressure better, the pulse was 120, the tongue 
moist, and the skin cool. Another scruple of calomel was 
f^iven witti two grains of opium, a blister put to the epigas- 

10 



66 THE PUERPERAL FJVER. 

trium, and the purgative mixture was directed to be resum- 
ed four hours afterwards. At six o'clock on the following 
morning the pain and tenderness of the abdomen remained, 
though in a subdued degree. The pulse was 138, the 
tongue moist, and she complained of head-ache. Two 
copious stools had been procured from the purgatives, but 
as it seemed most desirable to induce further evacuations 
ten grains of calomel 'and the same quantity of jalap were 
exhibited, and the mixture ordered to be very frequently 
given, till copious motions should succeed. The abdomen 
was fomented, and twenty leeches were then applied over 
it, and also reapplied at one o'clock, with a blister to the 
sternum on account of the continuance of pain. At nine 
o'clock in the evening, the pulse was 130, and \ery soft* 
She had pain in the belly as of colic unaffected by breath- 
ing, was restless, and apparently much exhausted. Forty 
drops of laudanum were prescribed at nine o'clock, one 
grain of solid opium at eleven, and another four hours after- 
wards. She slept well and the next morning had no pain, 
breathed freely, lay in an easy posture, the pulse had fallen 
to 122, was fuller as well as stronger, and the bowels were 
opened, but she vomited her diet drink for the first time, 
the lochia were now suppressed, and the tongue was brown 
and dry. In the forenoon the pulse was once as low as 
102, at mid-day it was 122, and at nine o'clock in the eve- 
ning, it rose as high as 138, and was then strong and jerky. 
She had great pain in the back, shrunk much on the slightest 
pressure over the belly, and was highly irritable. There 
had been repeated vomitings, and the tongue in conse- 
quence was moist. She was again bled nearly to faintness. 
a cathartic enema administered, a scruple of calomel pre- 
scribed with two grains and a half of opium, and a purga- 
tive mixture, which was to be repeatedly administered four 
hours afterwards till copious stools should be procured. 
The blood drawn was exceedingly buffed. It eased her, 
and she slept. But at seven o'clock on the morning of the 
18th she still shrunk on pressure, she had passed several 
copious stools involuntarily, and her countenance was anx- 
ious ; but no vomiting had occurred from the time which 
she took the calomel and opium, and the pulse was only 
1 1 8, strong and resisting. Throughout the day, she became 
extremely restless and irritable, and complained much of 



THE PUERPERAL FEVER. 67 

the blister ;. at six o'clock in. the evening her pulse was ex- 
ceedingly quick, and as she was still very restless, twenty 
drops of laudanum were given, which quieted her for about 
an hour, when she again became restless, and gasped as if 
for air. Her voice continued loud, and her movements 
strange and hurried up to nine o'clock, when she attempted 
to leap from the bed and expired. 

The body was examined ten hours after death* About 
nine ounces of serous effusion was found in the abdomen, 
and a few bands of lymph united the hypogastric convolu- 
tions of the intestines. The bowels were very empty and 
contracted, except that the commencing colon was distended 
by gas. A patch of purple congestion was discoverable 
here and there on the peritoneal and villous coats of the 
intestines. The spleen was unusually small but sound ; 
the liver and kidneys were also in a natural state. The 
portion of the peritoneum which invests the uterus was 
inflamed, especially near the lateral vessels, and the exte- 
rior and interior of the bladder was of a similar pink 
colour. Much organic disease existed in the rectum, which 
was thickened, rugose, very contracted, and green on the 
inside, with subjacent and injected vessels dimly seen 
through this green lining. This peculiarly coloured ap- 
pearance was equally marked in the coecum, and com- 
mencing colon, and most probably extended throughout 
the whole colon, though a circumstance occurred to pre- 
vent us from ascertaining whether this was really the fact. 
In the chest, no derangement was visible, except the re- 
mains of previous disease, namely, adhesion of the whole 
right lung to the surrounding parietes. The brain was 
perhaps. firmer than natural, its larger vessels well emptied, 
but the choroid plexus, and the pia mater of the inferior 
surface of the cerebrum and cerebellum, especially of the 
latter, were vividly red. 

Besides the pain in the right flank which this patient 
stated to have subsisted during gestation, she also subse- 
quently declared, that she had suffered during the whole 
of her pregnancy inconceivable pain " in the bottom of the 
back and in the inside." She only made this statement 
however at a late period of her disease, but it elucidates the 
morbid appearances of the rectum, and colon. This case 
was exceedingly embarrassing to me on the outset on ac- 



ua THE PUERPERAL FEVER. 

co.untof the pain which existed before and during pregnancy; 
a j ui though the organic disease discovered after death satisfi- 
ed me, that no treatment could have availed, yet a mistake 
was committed, which requires to be pointed out for the sake 
of others. On the evening of the 14th of October the 
pain became more acute, and was attended by a marked ac- 
celeration of the pulse ; but the skin was so moist, as to 
induce me to exhibit an opiate, under an impression that 
the fever might be carried off by perspiration. Instead of 
this procedure, she should have been bled without a mo- 
ment's loss of time. In such a disease as the puerperal 
fever, the delay of a few hours in the beginning may 
make all the difference between failure and success; but 
as I fell myself into an error of this kind, it may serve to 
prove how much more easy it is to give directions to others 
than to follow them ourselves. If I had been aware of the ex- 
istence of an organic disease in the rectum, J certainly would 
not have prescribed calomel at all, much less in such large 
doses, but respecting the operation of this medicine some re- 
marks shall be made in the sequel. Considerable irritation 
occurred towards the close, attended with very violent ex- 
ertions of the muscles ; and perhaps, as a last resource, 
opium should have been given more freely, and physical 
force mildly applied to restrain the motions. Irritation and 
muscular exertion are frequently the immediate causes of 
death, in diseases where great exhaustion exists, and par- 
ticularly if much blood had been previously lost; and 
hence we often see after uterine hemorrhage the greatest 
danger result from the combination of irritation and ex- 
haustion, and we find the greatest advantage from opium, 
and from keeping the body quiescent by every precaution. 
Now it is not impossible but the exhaustion and irritation 
which supervened in the last stage of this case may have 
been connected with the previous loss of blood, which was 
upwards of 80 ounces in four days; though I cannot take 
upon me to say whether that exhaustion and irritation might 
have been removed by opium and mild restraint, and only 
mention the circumstance here to put others on the watch in 
future, if they should be similarly situated. "Nothing is more 
painful to my feelings than the review of unfortunate ca^es, 
for 1 generally imagine (hat something might have been 
avoided or added for the better in treatment : yet it is our 



THE PUERPERAL FEVER. 09 

duty to publish such cases much more frequently than 
is done, since our recorded failures may serve to guard 
others from the wreck which we ourselves have witnes- 
sed. 

Lydia Jutt, a single women, aged 23 years, was deliver- 
ed of her first child on the evening of the 15th of October, 
after an easy and rapid labour. On the night of the 1 7th. 
she was attacked with rigor, succeeded by fe\er^ head- 
ache, abdominal pain with tenderness, and the pulse rose 
to 120 in the minute. As soon as these symptoms wer£ 
fairly developed, about three hours after delivery, she was 
bled copiously ad deliquium, after which ten grains of calo- 
mel with ten of jalap were given, and followed up, two 
hours afterwards, by repeated doses of the sulphate of mag- 
nesia in an infusion of senna. These medicines produced 
many copious evacuations. The pulse, which before the 
bleeding and purging, was 120, had fallen to 100 by the 
morning of the 18th. there was then no pain of the belly, 
and the tongue and skin were moist. In the course of the 
day a blister was applied between the shoulders, and an 
ounce of castor oil ordered, the first as an irritant to divert 
inflammatory action to the surface, and the last to keep the 
bowels free, which had only been once moved that morn- 
ing. The inflammatory symptoms of the abdomen return- 
ed, however, on the night of the 18th, and she was bled 
again to fainting. The blood was very buffed. Castor oil 
and draughts of the sulphate of magnesia and infusion of 
lenna were given until she was plentifully purged. She 
slept in the night, and at seven o'clock next morning, she 
had no pain, the pulse was 115 and very soft, the tongue 
clean and the skin moist. She remained free from uneasi- 
ness till the 22d, when she was attacked by fever and head- 
ache, for which she was bled to faintness with complete re- 
lief. An opiate was given at bed-time, she slept well, and 
from that time continued convalescent, till she was discharg- 
ed from the hospital cured, about three weeks from her con- 
finement; her boweis however during that term having 
been kept free by gentle laxatives, with now and then a 
smart cathartic. In this instance the effect of copious 
bleeding* and purging was as highly favourable as the most 

* In this case probably upwards of 50 ounces of blood were drawn in the 
?hree operations. 



THE PUERPERAL FEVER. 

sanguine expectations could have anticipated ; and they 
were equally so in the following case, if allowance be made 
for its more formidable character. 

Sarah Rock, a single women, aged 19 years, was deliver- 
ed of her first child on the 21st of October, after a labour in 
which she rather suffered from the resistance of the soft 
parts. About nine o'clock on the morning of the 23d she 
was attacked by a rigor of an hour's duration, succeeded 
by some pain of the head and loins, with a soft, weak pulse, 
upwards of 120 in the minute. She took an ounce of cas- 
tor oil. The head-ache and lumber pain disappeared but 
she had pain in the region of the uterus, especially on pres- 
sure. Venesection was ordered at noon. When about ten 
ounces had escaped, the blood ceased to flow, and the pain 
had totally departed* A purgative enema was prescribed, and 
also another ounce of castor oil. At six o'clock in the eve- 
ning she was again bled ad deliquium, on account of ab- 
dominal pain and tenderness, with a return of the head-ache. 
The pulse continued to be exceedingly weak, and 138 in 
the minute, she lost the head-ache after the second bleed- 
ing, though she still had pain on pressure in the hypogastric 
region. Four copious, fetid, and somewhat solid stools 
were passed, of a pretty natural colour. The mixture of 
salts and senna was ordered to be frequently given, till it 
should operate. But as at ten o'clock at night no further 
evacuation had been procured, and as symptoms of abdom- 
inal inflammation existed, half an ounce of castor oil was 
given every hour, that an action on the intestines might be 
promptly and plentifully established. Two hours after 
midnight the symptoms remaining the same, she was again 
bled freely and to fainting, took two grains of opium, and 
almost immediately afterwards, she displayed some delirium, 
which however was soon removed by sound sleep. At 
eleven o'clock the next day, the pulse was only 90 ? the skin 
warm and moist, and the bowels open. She had no pain 
of the abdomen on forcible pressure, lay upon her side, 
breathed easily, and had a tranquil expression of the coun- 
tenance. She slept well on the next night, and the pulse 
was only 86 on the succeeding morning, and she had no 
pain whatever. From the 25th to the 29th of October, 
the symptoms remained highly favourable ; but on the lat- 
ter day she had head-ache, quick pulse and quick breathing. 



THE PUERPERAL FEVER. 71 

for which an enema, some castor oil, and an infusion of salts 
and senna were prescribed ; but though these moved her 
bowels, the head-ache continued to be harassing, and she 
was therefore again bled ad deliquium, and her bowels were 
freely opened. She took two grains of opium at five o'clock 
on the morning of the 30th, slept soundly afterwards, and 
from that period rocovered apace. 

This case gave me considerable anxiety, because it com- 
menced and continued with a quick, weak, and soft pulse, 
which is always an unpleasant attendant ; since combined 
weakness, softness, and quickness of the pulse show an 
unusual relaxation of habit, and in all inflammatory diseases 
is much more to be dreaded than a strong resisting pulse in 
the commencement. The first bleeding was employed 
about three hours after the commencement of the disease, 
the second three hours after the first, and the third eleven 
hours after the second ; so that in about fourteen hours 
faintness was thrice induced, and she had lost about fifty 
ounces of blood, and the bowels had been freely opened. 
The fourth bleeding was five days after the third, and re- 
moved a head-ache and general excitement which probably 
threatened a relapse of the original disease ; at least I have 
seen such an excitement, when allowed to pass on, repro- 
duce all the symptoms of abdominal inflammation at last, 
though at its onset it was unconnected with inflammation. 
Another but much milder case occurred nearly about the 
same period, but in it bleeding was only once necessary, 
with the co-operation of purgatives. Independently of 
these six cases of the puerperal fever, I have seen four in 
private practice, in the first of which, bleeding was four 
times used to the total amount of about fifty ounces, in the 
second, thrice to a similar quantity, in the third, twice to 
the total amount of about thirty ounces, and in the fourth, 
between twenty and thirty ounces of blood were abstracted 
at once ; but in all these four cases, purgatives were libe- 
rally employed in the beginning, and in two of them leeches 
applied to relieve local symptoms, and also opiates admin- 
istered to allay general irritation. From these facts, then, 
it appears that even in London where child-bed fevers are 
said to be. more fatal than in the country, only one case in 
ten has terminated mortally under the depletory practice : 
and as that case was combined with an old organic disease. 



72 THE PUERPERAL FEVER. 

one would perhaps be led to hope, that the mortality in 
general might not be more, where the disease is fairly met 
and encountered from the beginning ; for after all the gene* 
ral result will in a great measure depend upon this circum- 
stance, and it ought again and again to be reiterated, that 
unless the disease be early met, the mortality must be much 
greater. But there are some practitioners who, from un- 
conquerable peculiarities of their mental constitution, think 
that they pursue depletion properly when timidly adopted 
in the beginning, or perhaps rashly towards the close when 
universal relaxation exists ; and a conscientious impression 
being thus left upon their minds, that depletion is not so 
successful as has been reported by others, its utility by them 
is never fairly estimated, merely because it has never been 
fairly tried. It is right, however, to mention, that all the 
subjects of the above ten cases were women in the vigour 
of life, and likewise tolerably robust, with a single excep- 
tion ; and therefore, with that one exception, the depletion 
was employed in constitutions highly favourable for its effi- 
cacious influence. When this disease attacks women who 
are broken-down by repeated child-bearing, or any other 
cause, they stand a much less chance of recovery in the 
main run. The same priciples of treatment, however, 
obtain in them, yet thoseprinciples require to be modified in 
their application, inasmuch as similar effects upon the con- 
stitutional excitement and the topical inflammation would 
be produced by a much less amount of evacuations ; and 
as the constitutional excitement and topical inflammation 
not only run a more rapid course in such cases, but are 
followed by greater relaxation of the whole habit, there is 
more necessity for at once cutting them short at their first 
invasion. 

The cases of the hospital puerperal fever which have 
been detailed, and which similar ones preceded and follow* 
ed, were considered as contagious by a practitioner of 
great talent and experience, who was attached to the In- 
stitution where they appeared ; and in St. James's Infirm- 
ary, a similar disease occurred about the same time, which 
was successfully treated by similar means, as will be seen 
from the excellent letter of Mr. Alcock in the Appendix. 
From what 1 have .myself observed of the hospital puerpe- 
ral fever, it would appear to me as controllable as any other 



THE PUERPERAL FEVER. 73 

modification of the disease when accompanied with general 
excitement and topical inflammation. In confirmation too 
of this opinion Dr. Gooch, whose experience in the hos- 
pital puerperal fever has been so extensive, recently told 
me, that though he had seen more formidable cases in hos- 
pital than in private practice, yet even in the former he 
had lost very few. From all he has seen of the disease, 
he has been led to the conclusion, that the only effectual 
remedies are bleeding and purging very boldly and very 
early employed : but he considers, that these measures 
used moderately at this period do little or no good, while 
used late they do harm, especially bleeding ; and he has 
observed, the curable stage, in many instances to pass over 
so rapidly, that unless the first approaches of the disease 
be detected, cases will now and then be lost, which might 
have otherwise been saved. Indeed, upon this point, I 
could accumulate evidence, from some judicious accouch- 
eurs, who have reported to me their success in the Public 
Establishments which they attended ; and I must not forget 
to mention in particular, that Dr. Ramsbotham has long 
and advantageously employed bleeding and purging in the 
various forms of the puerperal fever, as presented to his 
observation in the metropolis. When any strong contrast 
arises between present improvements and past prejudices, 
some men pretend that the disease in question is not the 
same now as it was formerly ; so reluctant is the human 
mind, in certain instances, to humiliate itself by acknowl- 
edging as erroneous what it has long considered as right. 
But an accurate investigation would distinctly prove, that 
the puerperal fever has undergone no change in its nature, 
the change being wholly limited to our pathology and treat- 
ment. 

In his Lectures, when speaking of the puerperal fever, 
the late Dr. William Hunter used to say — " Treat them in 
what manner you will, at least three out of four will die. 
Upon examining the uterus, the viscera, and every other 
part are found to be inflamed. There is a quantity of 
purulent matter in the cavity of the abdomen, and the in- 
testines are all glued together. The disease rages so 
violently, that every process of nature is set aside ; and 
there is no secretion of milk in the breast. From what I 
have seen at different places, and in my private practice, 

11 



74 THE PUERPERAL FEVER, 

this fever often happens ; and yet when it does, it is the 
only case in midwifery, in which so little is to be done. I 
would observe then, first, that in the hospital I have seen a 
great many of these, and particularly in one year, when it 
was so remarkably prevalent there. It was so bad, that 
not only every gentleman belonging to the hospital, but all 
our friends in town had a consultation to think whether it 
was not better to shut up the house. In two months thirty- 
two patients had the fever, and only one of them recover- 
ed. We tried various methods. One woman we took 
from the beginning and bled her, and she died. In another, 
we gave cooling medicines, and she died. To a third we 
gave warm medicines such as confect. cardiac, cordial 
iulep, mithridate, &c. and she died. We tried these te 
save their lives, but every thing failed."* 

If the puerperal fever were now treated in the same 
vague way as in the above inflammatory modifications, it 
would be equally fatal in our experience as it was in that 
of Dr. William Hunter; and as he was an individual of 
transcendent talent, it is gratifying to reflect, that the ad- 
vanced state of medical science has enabled us to succeed 
in a point where even his genius failed. In conversing 
upon the subject of the puerperal fever, I have occasionally 
known practitioners to assert in general terms the utter in- 
efficiency of bleeding. But the moment that I began to 
enter into particulars, it was discoverable, that with them 
bleeding was a term to which they attached a very differ- 
ent meaning from myself; and that, like Dr. Leake, they 
talked of having bled copiously when a few ounces of blood 
only were drawn, without any strict regard to the stage of 
the disease, or to the effect produced. It is to be regretted, 
in the records which we possess on febrile diseases, that 
authors have seldom stated with minuteness how much and 
how often blood had been drawn, nor given an account of 
all the symptoms present at each operation; for if we had 
been possessed of this information, we should have been 
enabled to discover why some failed and others succeeded, 
and thus to reconcile those discrepancies of opinion which 
to some have seemed inexplicable. Were it possible, that 

* A part of this passage, which Dr. Gooch favoured me with, has been 
cited by Boer, a German writer on Midwifery, who imagined that he had 
found a specific for this disease in one of the preparations of antimony. 



THE PUERPERAL FEVER. 75 

the leading physicians in Europe could at this moment de- 
clare bleeding to be prejudicial in the beginning of the pu- 
erperal (ever, attended with general excitement, I would 
enter *m y firm protest against the declaration; because 
whatever respect I might feel for such an united authority, 
it could not, and should not prevail for an instant against 
the plain evidence of my sense?. But if any one were to 
affirm that bleeding was inadmissible, when the general 
collapse is fully established in the puerperal fever, then I 
would cordially join with him in the opinion, nay go even 
further, and assert the same thing of the inflammatory form 
of typhus, and indeed of every other inflammatory disease. 
In the treatment of the puerperal fever it will sometimes 
be found a point of great difficulty to determine with pre- 
cision whether a vein ought to be opened or not when the 
practitioner is consulted rather late than early in the at- 
tack ; for though it has been tried in the preceding pages 
to mark the stage of excitement from that of collapse, yet 
the shades of difference are not always so distinct as to be 
clearly perceptible ; and as peritoneal inflammation and 
pyrexia occurring in the child-bed state often remarkably 
depress the vital powers in the acme of their intensity, w T e 
should be cautious not to deceive ourselves by affixing too 
narrow a limit between the stages. On the other hand, 
especially when we have previously bled, we should not 
carry our prejudice in favour of the lancet so far as to in- 
duce us to employ it when the universal collapse has ob- 
viously succeeded the excitement ; since such temerity 
could only tend at once to sink the system under the 
shock of depletion, or at the least to increase a general 
irritation which w r ould accelerate the mortal issue of the 
case. Much must at all times be left to the discretion 
of practitioners, since it is impossible to embody in 
books all that can be observed at the bed-side, respecting 
those nice distinctions of symptoms upon which a good or 
bad practice may be founded ; and even if any one could 
embody all that he has himself impartially observed, still 
there is often something in the mind of others which, un- 
consciously to themselves, gives an accustomed and a fa- 
vourite colouring to most of their impressions. Some men 
have naturally such a decisive turn of intellect, that they 
are always ready to avail themselves of any single symp- 



76 THE PUERPERAL FEVER. 

torn which would appear to justify a bold practice, while 
others again are so constitutionally timid as to lean, in like 
manner, to any symptom which might favour a mild mode 
of treatment; and though it may be difficult, yet it is not 
impossible for a man so to regulate his mind as to be bold 
or cautious, according to the existing circumstances of the 
cases to which he may be called. It would, however, have 
been of considerable advantage to us if the circumstances, 
under which evacuations succeeded or failed, had always 
been pointed out, together with the measure, mode, and 
time of those evacuations ; for then, with more precision 
than at present, we might have estimated the power of this 
practice in the beginning and intermediate states, while we 
should also have been more guarded against its abuse in 
the very last stage of the disease. 

When from a cautious survey of all the symptoms there 
are grounds to believe, that the stage of excitement is past 
or upon the point of declination, every thought of general 
venesection ought to be abandoned ; and if any measures 
can then save the life of the patient, which indeed is most 
doubtful, laxatives and opiates are by far the .most likely, 
together with light nutritious food exhibited in small quan- 
tities at once. But it must be always recollected, when- 
ever a highly inflammatory disease has unimpededly run 
its course, that the vital organs are generally somewhere 
wrecked towards its conclusion ; so that if it were possible, 
at that advanced period, to abstract whatever remains of 
fever may be present, the patient would most frequently 
die from the organic mischief previously induced. Yet 
now and then a remarkable recovery does take place from 
the last stage of the puerperal fever, even when no proper 
measures had been used in the first. An instance of this 
kind once fell under my observation, in which an opening 
took place spontaneously at the navel, after the patient 
had struggled several days in extreme irritation and ex- 
haustion ; and the turbid serum and coagulable flakes, effu- 
sed into the abdomen from inflammation, were evacuated 
at this opening, which finally closed, and the long continu- 
ed hectic ceasing, the patient got quite well at last. 

But there are instances of exceeding delicacy where de- 
pletion has been employed in the first stages, and where it 
is difficult to say in the last whether the danger depends 



THE PUERPERAL FEVER. 77 

upon derangement of structure and function, or upon mere 
nervous irritation and weakness ; and in all of such doubt- 
ful cases, the best thing that can be done is to attempt to al- 
lay the irritation by full doses of opium, and to remove the 
weakness by light nutriment, since irritation and exhaus- 
tion may sometimes be the causes of death. Once 1 was 
consulted for a lady deemed to be dying of the puerperal 
fever, after copious venesection and purging had been most 
judiciously directed in the outset. When I saw her the 
face was ghastly pale, the pulse small and tremulously 
rapid, she gasped anxiousl) for air, and shrieked out now 
and then from the pain of a blister which had been previ- 
ously applied. Under some faint expectation that irritation 
might be the principal cause of her present suffering., the 
blister was removed, and a large opiate administered : she 
soon fell into a quiet sleep, awoke some hours afterwards 
with a soft slow pulse, a warm moist skin, and from that 
time recovered rapidly. 

In the beginning of the puerperal fever, after evacua-* 
tions, blisters have often an excellent effect ; but in the 
advanced stages, the irritation which they produce may be 
dangerous, as i have more than once witnessed. Through- 
out the stage of excitement the patient should be lightly 
covered, and the room well but cautiously ventilated, the 
temperature t)f which should then rarely exceed 60° of 
Fahrenheit; but in the last stage, when the animal heat^ 
like the powers of life, suffers a diminution, the covering 
of the patient and temperature of the room should be 
warmer ; while light and noise ought to be excluded as 
much as possible, for even the burning of a candle or the 
ticking of a clock, at such critical moments, might prevent 
sleep, or prove the cause of additional irritation. When 
the abdominal inflammation is of the acute kind, it gene- 
rally proceeds with great rapidity, so that in these cases, a 
few hours lost in the commencement may be fatal to the 
patient; but when the force of such an inflammation has 
been broken in the beginning, and yet not subdued, it may 
still permit of further venesection, or at all events-leeches 
may be applied to the belly, which are often excellent 
•auxiliaries to general depletion. When the abdominal in- 
flammation puts on the sub-acute character, it is more slow 
and protracted, and of course admits of bleeding at a later 



THE PUERPERAL FEVER. 

period than the former: bat in both laxatives or purga- 
are always indicated so long as the excitement re- 
mains, and where there is room for doubt respecting b ced- 
ing, none in general may be entertained as to the proprie- 
: their administration, particularly the former. " 

^rd conversations with practical 
men have been extensive in regard to the puerperal fever, 
and. as 1 before hinted, those who have been most success- 
ful in the treatment of the disease trust chiefly to bleeding 
and purging in the early stages, but though they thus remark- 
ably coincide in one great principle, yet there is a difference 
amongst them. Some practitioners are decidedly in fa- 
vour of calomel and similar purgatives of the drastic kind, 
whilst others are decidedly against these, preferring milder 
aperients, but especially castor oil. which the\ conceive to 
be better, inasmuch as it produces full evacuations without 
irritation. Perhaps an impartial and experienced critic 
might be inclined to think, that it was of little consequence 
what purgatives were ordered, provided an action w c 
cited and kept up upon the bowels for a sufficient length of 
time : and yet as most purgative medicines have a peculiar 
as well as a common effect, this discrepancy of opinion may 
be more worthy of notice than might at first sight appear. 
In regard to castor oil. it is usually thought that it merely 
evacuates what may be lodged in the boweis. with 
ing any secretion from their villous surface: but. when 
good.* I fa orally observed, that i* copi- 

ous stools as almost any other aperient, and with much 
less irritation than most: and thef ircumstances 

render it a most desirable drug in those abdominal inflam- 
mations where the intestines t,. ..and 

* W if Indian ca=tor oil, v.- a very pale 

considered as a Jaxative only, but what is call 

tly a purgative ; and 

•-••, that be 
casioo may - i coaeidefft- 
by aftendii timrteiy to the prepara- 
tion or e; for the \ times 

- 

-..j it is pr^r. too little 

ted for 



- 




80 THE PUEFIPERAL FEVER. 

heart, and the animal heat approach towards their natural 
state, then large doses of calomel may be highly injurious, 
from the great and universal relaxation which they are apt 
to induce in that condition ; nay there may be certain states 
of the body, even in fever, where a similar relaxation is 
induced by large doses of calomel, and from what Dr. La- 
batt has mentioned, it would be desirable to ascertain what 
those states are, which modify its influence so remarkably. 
In the exhibition of calomel, as in the employment of blood- 
letting, it is to the effect produced that we must chiefly look, 
and if a desired effect can be produced by an ordinary mea- 
sure, it is surely all the better 5 but where the circumstances 
are so unusually formidable as to render an ordinary measure 
of no avail, then we must deviate from the common routine, 
and be bold in proportion to the urgency of the case. 

The best way to ensure the operation of purgatives in 
the puerperal fever is to bleed freely at first ; and though 
having great faith in the anti-inflammatory powers of calo- 
mel as an alterative, yet in this rapid disease it is chiefly its 
purgative power which I would regard. In a very large 
majority of cases, the stools are rendered morbid from the 
primary seizure of the puerperal fever, and in such calomel 
should always be premised ; but in those instances, which 
perhaps are exceedingly few, where the stools are natural 
from the onset, probably castor oil is in general preferable* 
No purgative changes the appearance of the stools more 
than calomel, and 1 believe, that many mistakes are com- 
mitted from prescribing this preparation in order to render 
the evacuations natural ; when in fact their morbid state, 
if not actually occasioned in the first instance, is at least 
afterwards maintained by the unnecessarily repeated exhi- 
bition of this medicine. It is oversights of this kind which 
often bring the best agents into an unmerited disrepute ; 
and it cannot be denied, where calomel is improperly given, 
that it may sometimes produce an irritation and exhaustion 
fatal to the patient. My principle in the treatment of high- 
ly acute diseases is, to make a decided impression on them 
in the onset by powerful measures, and to treat them mild- 
ly towards the close ; but between the onset and the close 
an intermediate state of disease exists, which requires a 
treatment intermediate between those adapted to the first 
and last stage. However accurately generally principles 



THE PUERPERAL FEVER. 81 

may be laid down in books, still their successful application 
in practice must entirely depend upon the discernment of 
him who applies them •, and that practitioner will succeed 
best who most judiciously modifies the application of those 
principles by the stage of the disease, the age, previous hab- 
its, constitution, and other peculiarities of the sick. But 
it is necessary to turn from this digression, and to $ay 
something more respecting the changes, which purgatives 
induce on the appearance of the stools. 

Erasistratus confidently maintained, that most purgatives 
altered the nature and colour of the alvine avacuations 5 
and though this remarkable fact has been disregarded in 
modern publications, where purgatives are constantly re- 
commended, yet it is familiar even to nurses. Calomel 
often changes the stools to a greenish, or dark brown colour, 
and in fever not unfrequently produces those glary, oily 
directions, which some have erroneously supposed to be pa- 
thognomonic of hydrocephalus when they occur in children; 
indeed the nature and colour of the feces are so varied by 
calomel, as to render it highly probable, that some portion 
of it is decomposed in the bowels, either by the bile, or 
by other secreted fluids. The sulphate of magnesia 
tends to darken the stools, as likewise all prescriptions 
which contain sulphur : the infusion of senna, too, has a 
similar effect, and even aloes when given in solution ; but 
rhubarb renders the stools of a deeper red than natural, 
and castor oil generally shows them as they really are, while 
magnesia makes them lighter. These few hints are only 
given in illustration of the doctrine, which might be sup- 
ported by many others ; and if it were necessary, it also 
might be easily proved, that drinks and diets contribute in 
like manner to give peculiar tinges to the stools, which, 
even when passed in a natural state, are darkened by ex- 
posure to the air.* Now that purgative medicines are so 
much resorted to in almost all diseases, whether acute or 
chronical, these suggestions are only thrown out to caution 
the inexperienced against their indiscriminate continuance : 
for it has almost become an admitted principle in therapeu- 
tics, that we should continue to purge less or more while 

* Similar observations might be made respecting the urine, the quality 
of which is affeeted by the medicines, and even by the food which we 
take. 

12 



m THE PUERPERAL FEVER. 

the stools remain unnatural ; and yet it will be readily un- 
derstood how erroneous that principle may be, since the 
very medicines exhibited may be the cause of the morbid 
evacuations. At the same time, it should not be concealed 
from the student, that the secretions, especially those of the 
liver, and villous coat of the bowels, are almost always vi- 
tiated by febrile attacks. Purgatives are therefore requi- 
site not only to correct these vitiated secretions, but also to 
operate locally and generally as evacuants, particularly 
where visceral inflammation exists ; and if there be one 
disease more than another where they are indispensably 
necessary and highly useful, it is unquestionably the pu- 
erperal fever, in which they justly rank next to vene- 
section. Yet from what has been said the practitioner 
will perceive the propriety of not pushing the purgative 
plan too far when the symptoms have been overcome, from 
the mere unnatural appearance of the stools ; but on the 
contrary, he will then select laxatives which, while they 
keep the bowels regular, will soon enable him to ascertain 
whether the morbid stools have been the product of the 
disease, or of the medicines previously given. 

It will have been noticed, that opium was given in some 
cases of the puerperal fever, either to lessen the pain while 
the abdominal inflammation existed, or to allay irritation 
when that inflammation was subdued ; but as the adminis- 
tration of opium, during the presence of inflammation, is 
condemned both in the schools and in systematic works, it 
may be necessary to say a few words on the subject. Hav- 
ing early imbibed the common prejudice against opium, ac- 
cidental circumstances chiefly led me to doubt the sweeping 
dogmas respecting its being prejudicial in visceral inflam- 
mations ; and it has been by very gradual steps, that I have 
arrived at any thing like its true operation in such affections, 
seated in the abdominal cavity. Opium when given in 
health constipates the bowels, but this is so far from being 
the case in gastritis and enteritis, that it tends to assist the 
action of purgatives; and when exhibited in those corn-* 
plaints, in conjunction with proper depletion, it may fairly 
be accounted one of the best remedies. Yet as I have so 
often given it combined with calomel, it may be objected, 
that the result rather depended upon the combination than 
upon the opium alone. In some urgent cases, however, ) 



THE PUERPERAL FEVER. 83 

have been compelled, from the necessity of attempting im- 
mediate relief, to trust to opium merely, when previous 
bleeding and purging had produced little or no alleviation 
of the symptoms ; and in these the efficacy of opium was 
so remarkably great, as to embolden and justify me to give 
it in similar cases, when the ordinary measures in like man- 
ner had previously failed. Even here it may perhaps be 
contended, that as bleeding and purging had been in prior- 
employment, the agency of the opium might be reasonably 
questioned; but as a satisfactory answer to this natural 
scepticism, I can affirm that opium has been made the prin- 
cipal remedy, where, from a sort of necessity, the lancet 
and active purgatives could not be used. Since my ap- 
pointment to the Fever Institution of London, it has 
sometimes happened that patients, while just convalescent 
from a protracted disease, and while extremely weak and 
emaciated, were attacked with all the symptoms of gastri- 
tis or enteritis ; and as the peculiarity of their situation de- 
terred me from blood-letting, previous facts induced me to 
trust to very early and full doses of opium, in conjunction 
with blisters, and the mildest laxatives. Where this treat- 
ment has been promptly applied it has in general given the 
most perfect relief. Sometimes sixty drops of the tincture 
of opium have alone answered the purpose, but sometimes 
twice that quantity was exhibited at once, and a smaller 
dose repeated soon afterwards, if the pain were not reliev- 
ed by the first ; and as the test of its utility has been its re- 
moving the pain, it was always re-administered, at proper 
intervals, until the pain entirely abated. When the stom- 
ach has been very irritable, solid opium was prescribed in 
small pills, instead of the tincture, which nevertheless is 
generally retained except in extreme case, and which ope- 
rates more rapidly than the solid opium, though a combi- 
nation of both often answers exceedingly well. In cases of 
this kind, however, the opium was certainly exhibited under 
a state highly favourable for its efficacy, as they had only 
existed a short period ; and however great the general re- 
laxation might be from the previous disease, there was a 
nervous irritation also existing, which made opium more 
peculiarly applicable. Patients are often brought into the 
Fever Institution in the last stage of fevers, proceeding 
from various causes, in which general depletion is entirely 



84 THE PUERPERAL FEVER. 

out of the question, from the excessive prostration of 
the general powers ; and even in some of these cases, com- 
bined with gastritis or enteritis, large doses of opium, with 
blisters and laxatives, have succeeded when the ordinary 
means must have been wholly unavailable. Yet in pro- 
tracted cases of fever combined with abdominal inflamma- 
tion, ulceration of the villous coat of the bowels is by no 
means uncommon, not to mention other organic derange- 
ments, and therefore the general chances are greatly against 
opium, or indeed against any other mean then administered. 
The two most remarkable effects of full doses of opium 
in gastritis and enteritis are the relief to the pain and the 
reduction of the pulse ; so that the patient often falls asleep 
shortly after their exhibition, and the pulse which had been 
previously small and quick, will become full and slow. 
Pain is a direct irritant to the heart and thence to the ar- 
teries, and in many cases thus prolongs inflammation. Tn 
external burns, where pain is the most urgent symptom, 
those applications are the best which relieve it soonest, 
and hence the fefficacy of turpentine. In gastritis and en- 
teritis, opium may be said to be applied almost directly to 
the part, and this may be one reason for its superior effica- 
cy in them. In peritonitis strictly so called, where the 
pain and tenderness are diffused, it is by no means so use- 
ful, its benefit being most conspicuous where the pain and 
tenderness are circumscribed, as in enteritis, gastritis, or 
hysteritis. Yet in the puerperal fever, in which the peri- 
toneum chiefly sustains the intensity of the inflammation, 
opium may often be given with considerable advantage, 
where the local pain and constitutional irritation are exces- 
sive ; though in that stage of excitement it must not for a 
moment be forgotten, that bleeding and purging are the 
principal measures. When the stage of collapse approach- 
es, as bleeding is highly prejudicial, opium may perhaps 
be accounted the primary measure, since the allaying of 
irritation is then the principal object. Whenever opium 
is administered in any species of abdominal inflammation, 
the dose should be large, for a small dose often stimulates, 
-whereas a large one is a direct sedative ; and if 1 had been 
sooner aware of this fact, it would have enabled me to avoid 
some errors into which I formerly fell, in the exhibition 
and estimation of this peculiar drug. Between that state 



THE PUERPERAL FEVER. 85 

of the nervous system called irritation, and that state of the 
vascular system called inflammation, there is a most inti- 
mate relation ; so that in many instances when we prompt- 
ly allay irritation we prevent an inflammation, which would 
have otherwise occurred ; and even when inflammation 
exists in combination with much pain, we often find, that 
by allaying the pain we lessen or remove the inflammation. 
This acknowledged relation between nervous irritation 
and vacular inflammation has long been acted upon by sur- 
geons, who use opium more judiciously than physicians ; 
and indeed not only much fewer articles are used in sur- 
gery than in medicine, but they are far more precisely ap- 
plied in the former, both of which things show the higher 
advancement of that department of medical science. 

It is long since Heberden maintained the utility of opi- 
um in enteritis, and Clarke in the gastritis of warm cli- 
mates ; and an intimate friend has long resorted to its aid 
in these complaints, conjointly with the usual evacuations. 
But if any one were to generalize the idea, and give opium 
similarly in inflammation of the lungs and brain, he would 
soon bring discredit upon the practice ; for exhibited alone 
it is prejudicial in these diseases, as digitalis, to illustrate a 
converse proposition, is useful in inflammation of the lungs 
and brain, but of no benefit in abdominal inflammations. 
These curious circumstances we cannot explain, but for 
practical purposes it is enough to be assured of their truth. 
Probably opium has fallen into disrepute in gastritis and 
enteritis, because it has not generally been tried in suffi- 
cient quantities, and also because it is known to restrain 
the action of the bowels in health ; but as I hinted in the 
essay on typhus, the bowels sometimes cannot be moved 
when they are inflamed until opium be given, a fact of 
which I have had repeated proofs in the course of my prac- 
tice. Perhaps nothing has more retarded our advance- 
ment in the science of therapeutics than pre-supposing, 
that the operations of medicines are always similar in dis- 
ease and in health. If opportunities should occur, a few 
years hence it is my design to draw the attention of the 
faculty to a series of facts which will show, that the ope- 
rations of the same and different medicines are exceeding- 
ly varied by the states of the body under which they are 
administered ; and upen this principle it is hoped, that our 



§6 THE PUERPERAL FEVER. 

materia medica may be made to assume the form of a sci- 
ence, by deducing general principles from an ample col- 
lection of particulars, respecting the modus operandi of the 
most important agents in common use. These remarks 
have led me into a species of digression, but it will proba- 
bly be excused when it is recollected, that opium was one 
of the principal means which a late ingenious author re- 
commended in the puerperal fever. As that author saved 
some of his patients, in spite of the highly stimulant plan 
which he simultaneously adopted, it is but fair to infer, that 
the opium had been useful ; and since the powers of this 
medicine need further investigation, perhaps the bare allu- 
sion to the above circumstance may be useful to those, 
who shall hereafter investigate the puerperal fever, and 
other diseases combined with abdominal inflammation. 

Bleeding and purging, however generally successful, will 
not cure every case of the puerperal fever, and when they 
cannot cure it in the beginning, no other measures can, so 
far as my own information extends. But as the oil of tur- 
pentine has been brought into notice by Dr. Brenan, and 
as Dr. Joseph Clarke speaks highly of it in the last stage 
of that disease, it is only right, that its influence should be 
further investigated, when proper occasions occur; for 
however prone some physicians in Ireland may be to vaunt 
and to generalize its effects, and however opposed its exhi- 
bition to our admitted theories of inflammation, still if ex- 
perience has proved its utility under certain contingencies, 
we must not allow our pre-conceptions to retard its intro- 
troduction. The present age is one of independent think- 
ing amongst a large proportion of medical practitioners, 
and from this spirit has sprung the desire of some to try 
new remedies ; but at the same time it ought not to be 
forgotten, that many of our old ones required to be im- 
proved, by rendering their application more precise and 
particular. 

Five years have now elapsed since the first edition of 
this work was published, and it has been to me highly sat- 
isfactory to find, that the pathological and therapeutical 
principles then exhibited, have met with the strongest con- 
firmation from the observation and experience of many 
practical men ; but nothing has given me greater pleasure, 
than the excellent work which subsequently proceeded 



THE PUERPERAL FEVER. 87 

from the pen of Mr. Hey, junior, and which has not been 
more particularly noticed in these pages, merely because I 
wish it to be attentively perused by all those concerned in 
the practice of midwifery. Still however, before conclud- 
ing the subject of this essay, I must beg leave distinctly to 
state, that the treatment recommended is only meant as 
strictly applicable in all its parts to the puerperal fever, 
in a limited sense; for if we were to inquire of differ- 
ent men what they mean by the term puerperal fever, 
we should probably have many definitions attached to 
it of various import ; and it is much to be regretted, that 
both in books and in lectures much vagueness still exists 
for the want of a precise meaning to the general term pu- 
erperal fever. Were any one, then to ask, what is precise- 
ly signified in the preceding pages by the puerperal fever. 
I should be disposed to answer — it is an affection of child- 
bed, in which there is a general disturbance of the functions 
attended by an increase of the animal heat, an accelera- 
tion of the pulse, and evident or obscure symptoms of ab- 
dominal inflammation ; for I will confess, that I cannot 
frame any other definition which will justly comprehend 
those forms of child- bed disease which I have described, 
or most of those which I find specifically described by oth- 
ers, under the term puerperal fever. But it must be obvi- 
ous, that the above definition does not embrace all the 
modifications which fever assumes in the child-bed state, 
for though, when any shock occurs, the abdominal viscera 
are by far the most frequently affected, yet other parts 
may be simultaneously, or saparately inflamed ; and in- 
deed a fever may occur in child-bed where the blood is 
so equally distributed as to make it wholly unconnected with 
inflammation, a general disturbance of the functions, an in- 
crease of heat, an acceleration of the pulse, and a change 
in the secretions being then its leading signs. The doctrine 
of predispositions is one of peculiar interest to investigate, 
inasmuch as it has hitherto been greatly neglected. If a 
number of women in child bed, and the remark is applica- 
ble to other states, be exposed to any cause that excites the 
system into fever, that part will suffer most which had 
previously been in the most weak condition ; and hence in 
one the brain or spinal cord, in another the lungs or liver 
may be inflamed, and hence too the frequent occurrence of 



88 THE PUERPERAL FEVER. 

inflammation in the peritoneum. We want, therefore, a 
more enlarged classification of the febrile diseases of child- 
bed than has yet been given, though for practical purposes 
all those which are combined with inflammation may be re- 
duced within narrow bounds. Because whether the in- 
flammation be seated in the abdomen, chest, head, or any 
other part, and how much soever its characters may be va- 
ried by the tissue attacked, still it is inflammation which we 
have to encounter, and therefore the principles of treatment 
are similar ; and as for that form of fever which is simple 
on account of the equal distribution of blood, we have but 
so to control the excitement by evacutions and regimen as 
to prevent it from ultimately producing mischief in any of 
the internal viscera which might be latently predisposed 
to disease. Yet independently of these, there is a pecu- 
liar complaint of child-bed which has not been distinguished 
by any author with whom I am acquainted, and as 1 suspect 
that it has sometimes been confounded in practice with the 
ordinary puerperal affections, it may not be useless con- 
cisely to allude to it here. 

This peculiar affection of child-bed is ushered in either 
by sensations of chilliness, or by paleness and oppression, 
without such sensations : but in both cases the vital powers 
are so prostrate, that no regular re-action takes place as in 
common fevers ; so that the surface remains cool through- 
out, or there are merely short, partial, and irregular flushes 
of heat. The shock in some instances is so great that the 
secretions are all suddenly suspended, and the patient sinks 
with rapidity ; but in others the secretions are merely di- 
minished, and the patient lingers a few days. From the 
first, more complaint is made of exhaustion than of any 
thing elsej and there is such a striking depression in the 
countenance as to excite serious alarm. The face, lips, and 
whole surface are paler than natural, and the pulse is al- 
ways weak, if not irregular. Sometimes there is a limited 
pain in the abdomen, sometimes not, and the same may be 
asserted of the head and chest : but the breathing is mostly 
impeded and oppressed, and one of the earliest and most mark- 
ed symptoms is prostration of the appetite. Before death, 
gangrenous or livid spots are apt to appear on the extremi- 
ties, and the brain is embarrassed in some instances, but 
in others the mind is clear to the last. In such cases, dis* 



THE PUERPERAL FEVER. 89 

section does not reveal, so far as my examinations have 
extended, any of the usual remains of inflammation, that 
is to say there are no adhesions, no effusion of coagulable 
lymph, no formation of pus, nor internal gangrene from 
arterial fulness ; and the only morbid appearances have 
been, an unusual accumulation of blood in some part of 
the venous system, without any of those vermilion tints of 
the capillary arteries, which denote the previous existence 
of inflammation. From symptoms and dissections, then, 
this form of puerperal disease would appear to belong to 
what 1 have elsewhere denominated the congestive variety 
of fever ; but as I have only met with an instance of it now 
and then in the child-bed state, my observations are hardly 
sufficient for the ascertainment of its true pathology. The 
first shock seems to be communicated to the nervous sys- 
tem, a reduction of the animal heat immediately follows, 
the blood consequently retires into the deeper seated veins, 
and thence is perhaps at first returned superabundantly 
upon the heart, which is so remarkably oppressed in its 
action*as to render it highly probable, that the accumulation 
of blood about the right ventricle and large vessels finally 
retards the flow of venous blood from the other viscera. 
In the most violent modifications of this disease, if a vein 
be opened, little or no blood will issue from the puncture ; 
and in the less violent, what blood does issue sometimes re- 
mains a fluid gore in the vessel, or exhibits a gelatinous sort 
of opaque film on the loose dark crassamentum.* This 
kind of puerperal disease is probably rare compared with 
the others, as I have seen only a few cases of it myself, 
and, with the exception of two friends, have not known 
any practitioner who has seen many ; but all who have 
witnessed it, and my experience fully accords with theirs, 
have found it by far the most formidable of those acute 
diseases which attack after delivery, very few patients hav- 
ing recovered under any treatment. Perhaps it may be 
said, by those who are influenced rather, by names than by 
things/that this must be the iow child-bed fever described 
so well by the late Dr. John Clarke ; but in this disease, 

* It is no doubt to this modification, that Mr. Alcock has made an allu- 
sion in his valuable letter. From all that I have collected, it appears to 
9CCUY oftener in hospital than in private practice. 

13 



90 THE PUERPERAL FEVER. 

there is no re-action, and therefore fever, in the ordinary 
acceptation of that word, is absent; whereas in the affec- 
tion, which Dr. John Clarke has described, the re-action 
was early and perfectly developed. Besides the whole 
progress of the symptoms in the low child-bed fever, and 
the dissections after death clearly showed, that it was decid- 
edly an inflammatory affection, the intenseness of which 
was the cause of the apparent oppression ; but in the dis- 
ease in question a state the very reverse of inflammation 
ushers in and accompanies the disease, for so far from pyrex- 
ia being present, there is a deficiency of the animal heat. 

In this peculiar disease of child-bed, nothing can be done 
for the patient unless she be very early seen, and even then a 
cautious prognosis must be given, as the danger is imminent. 
An excellent practitioner once confessed to me, that he 
had never saved a patient in this complaint, and another 
acknowledged, that the mortality had been great, though 
he had used bleeding, purging, and all the means usually- 
resorted to for relief in acute diseases. From these facts 
it would seem that the congestive forms of fever in child- 
bed were more perilous, than those which occur under 
ordinary states of the system ; and this may probably de- 
pend in some measure upon the exhaustion, which is some- 
times super-added by the previous throes of parturition. 
The treatment of this disease must be regulated in the first 
instance by the constitutional powers of the patient, by 
the state of the animal heat, and by the apparent degree 
of venous pressure existing in some of the viscera. When 
a naturally feeble, or an exhausted subject is attacked, 
much more care will be required, especially in the use of 
evacuations, than in one whose general health and muscular 
tone had been good and unimpaired prior to the seizure ; 
and where there is so great a deficiency of the animal heat, 
that the whole surface feels cold to the touch, the practi- 
tioner must not be induced to use the lancet until some 
means be premised to restore the temperature, otherwise 
the patient may at once sink under the loss of blood. When 
the nervous system has sustained some great shock from an 
accident, the skin becomes universally cold, the blood re- 
tires from the surface into the interior, and the heart's ac- 
tion is extremely oppressed. Under such a state of things, 
it is an admitted principle in surgery not to bleed immedi- 



THE PUERPERAL FEVER. Bi 

ately, and indeed when it is done, death is often the direct 
consequence. Now in the most severe form of the disease 
under discussion, the constitution is a- most in a state similar 
to that which supervenes a serious accident ; for the nerv- 
ous system has sustained an universal shock, the blood has 
retired from the surface, and the heart's action is oppressed. 
Under such a combination of symptoms from an accident, 
the best surgeons hold it as a maxim not to bleed, and 
indeed they carry this doctrine so far, as to declare, that 
the lancet should not be used till re-action, or in other 
words till febrile excitement, shall take place. But though 
this doctrine be excellent and admirable, in those accidents 
where the vital powers are not so much overwhelmed as to 
prevent them from rallying into re-action, yet it would lead 
and has lead to great practical errors, when received as a 
rule from which there ought to be no exception ; for it 
sometimes happens in great shocks from accidents, that the 
patient dies before any signs of re action have appeared, 
and in like manner the same thing happens in those con- 
gestive diseases, such as that in question, which proceed 
from great and general shocks. As this diminished energy, 
then, of the nervous system, this preternatural reduction 
of animal heat, and this engorged state of the internal veins 
cannot continue to exist beyond a certain time without the 
greatest danger, or without destruction to the patient, it is 
the business of the practitioner to create re-action, which 
as it cannot be naturally must be artificially brought about, 
because it is the cure of this peculiar state. 

If possible, the patient should be at once immersed in a 
bath, at least 100° of Fahrenheit's scale, and strongly im- 
pregnated with salt. She should remain in it till the surface 
become warm, and when removed from it, the skin having 
been well dried and rubbed with warm flannels, she should 
be laid between warm blankets, and drink warm fluids, 
while bottles of warm water ought to be put to the feet, 
and a large bladder of warm water to the region of the 
stomach. But where the ordinary bath cannot be prepar- 
ed with sufficient expedition, a vapour one may be substi- 
tuted, and where that cannot be had, the other auxiliary 
means just mentioned must alone be employed, for the 
purpose of raising the temperature of the surface. When 
the shock communicated to the nervous system is extreme- 



m THE PUERPERAL FEVER. 

ly great, it is better, as before observed, to defer blood- 
letting until the coldness of the skin has been in some meas- 
ure removed, and even then, in venturing to open a vein, 
it will sometimes be expedient to administer internally a 
diffusible stimulant, such as aether, in order to excite the 
vis insita at the same time. In extreme cases, the blood 
only trickles from the orifice at first, but where the opera- 
tion does good, the heart gradually regains its force, and 
the pulse becomes free^ while the blood at last gushes out 
in a full stream ; and in those instances where the heart, 
instead of regaining, loses power, and grows weaker in its 
action, the arm should be immediately bound up, because 
continuing to abstract blood in that case might stop the 
circulation altogether. In short, blood letting will be ei- 
ther beneficial or the contrary, according as it raises or 
sinks the heart's action; and this is the criterion, by 
'which the practitioner must be guided in every modifica- 
tion of congestive disease. In this, and in all similar com- 
plaints, venesection must never be carried to syncope, for 
it must be recollected, that the object of bleeding here is 
to unload the venous system, and to bring the heart fairly 
into play ; and these ends being once accomplished, it 
would be bad practice to abstract more blood, which could 
only so weaken the heart as perhaps to make it unable to 
maintain the balance of the venous and arterial systems. 
On the contrary, in inflammatory diseases, where the 
heart's action is preternaturally increased, we bleed for the 
purpose of reducing that action, and therefore w r e may of- 
ten proceed advantageously in the operation till faintness 
is about to supervene ; but even in such examples, espe- 
cially where much blood has been drawn, we should always 
make a point of watching the very first indications of ap- 
proaching faintness, that the patient may be laid flat down 
at once, and all motion restrained ; for I do believe, that 
for want of such precautions, blood-letting, even in inflam- 
matory diseases, has now and then led to a fatal result, 
particularly in young children, who much more readily 
than adults may be lost in syncope. In fact, young chil- 
dren should scarcely ever be bled to syncope, since in them 
it may sometimes lead to mortal convulsions. 

But, to return to the consideration of this congestive dis- 
ease of child-bed, it ought to be remarked, that venesec- 



THE PUERPERAL FEVER, 93 

lion must be still more guardedly employed, in subjects 
who are constitutionally weak than in those who have been 
previously strong; and in both all idea of the operation 
must be abandoned unless in the very onset of the attack, 
where the congestion is apparently so great as to be threat- 
ening the destruction of some vital organ, andbearing^down 
by its pressure the general powers of the body. In those 
cases where the hot-bath and blood-letting answer the best 
purpose, the re-action follows without the necessity of any 
other measure ; and when that re-action is once establish- 
ed, the disease having assumed a new character, must be 
treated as simple or inflammatory fever, according to its 
symptoms. But in many instances of this congestive com- 
plaint of child-bed, these means will only have a partial 
effect, or fail entirely ; and in such the measures upon 
which I have most reliance, in conjunction with blisters, 
are calomel, opium, and camphor given in repeated doses, 
as directed in the essay on typhus, till the skin shall be- 
come warm and moist. In some examples of congestive 
disease, not occurring in the child-bed state, I have seen 
beneficial effects from emetics ; but not having yet ascer- 
tained the precise states under which they are indicated or 
contra-indicated, I can only mention them as means de- 
serving of investigation. As the bowels are frequently 
loaded in puerperal women, large cathartic injections 
should always be exhibited on the first attack, and laxa- 
tives or purgatives afterwards exhibited so as more com- 
pfetely to clear the intestines. Bujt it is only in the onset, 
that purgatives should be given, and even then they should 
be spared so long as the surface remains cold ; while in the 
advanced stage, they should be wholly omitted, as their 
operation might irretrievably sink the strength. Upon the 
whole, the pathology and treatment of all affections con- 
nected with venous congestion, have received the least 
attention, and are therefore the most open to improve- 
ment ; and my chief object in noticing this peculiar dis- 
ease of child-bed, was to confess my imperfect knowledge 
of its nature and cure, that others might hereafter be led 
to undertake their more complete illustration. And if I 
have spoken confidently of those child-bed diseases which, 
being attended with universal excitement and topical dig- 



94 THE PUERPERAL FEVER. 

order, have been comprised under the general term puer- 
peral fever, that confidence rests on an ample body of evi- 
dence ; yet the treatment even of these diseases is so far 
from being perfectly accomplished, that all which has been 
written on the subject, ought only to be made the ground 
for advancing towards higher attainments, and more cer- 
tain results, 



APPENDIX No. I* 



Letter from J. T. Gregson, Esq. Surgeon in Sunderland. 
Addressed to the Author, containing two Cases of the 
Puerperal Fever, and some Observations on that Dis. 



ease* 



Sunderland, Nov. 1st 1813. 
Sir, 

FROM the beginning of January to the beginning of* 
October in the present year, forty cases of the puerperal 
fever have occurred in my practice ; about twenty of those 
cases have been attended with me, or for me, by my late 
assistant Mr. Gregory,! and I believe, that you have near- 
ly attended an equal number with me. This gives me 
much satisfaction, because, in matters of this nature, collec- 
tive testimony is always the most desirable and conclusive. 

The disease was marked by such strong characters that 
it could not be easily mistaken, and I have been particu- 
larly mindful to exclude, from the above number, every 
case in the least degree ambiguous. 

Of the forty patients afflicted with puerperal fever, 
four only died, and the remaining thirty six are now living 
testimonies of the efficacy of the treatment adopted. 
The consideration of this latter circumstance is extremely 
consolatory, and, perhaps, it authorises me to say, that the 
success of the practice is unexampled in the records of 
medicine, and, likewise, confidently to hope, that the 

* The first Appendix is subjoined, because it contains much information, 
respecting the Puerperal Epidemic which appeared in the North of Eng- 
land, and the second because it contains the practical results of two indi- 
viduals who have narrowly observed the Febrile Affections of Child-be^ 

f Now Surgeon in Moukwearmoutho 



96 APPENDIX I. 

publication of your treatise on puerperal fever may be the 
means of saving many valuable lives hereafter. 

While only three solitary examples of this disease occur- 
red to some practitioners, and while it was unobserved by 
several others who lived in the same town, it may appear 
rather singular at first sight, that so many should have oc- 
curred to myself and my assistant. The cause of this I 
cannot pretend fully to explain, but I should be wanting in 
common liberality if I were to make any hesitation in assert- 
ing, that the disease which appeared in my practice was 
highly contagious, and communicable from one puerperal 
woman to another. For some time I was not aware of this 
important fact. The cases which fell under my care, with 
a few exceptions, took place among poor women, who lived 
in confined situations, and in small apartments, in which 
fires were kept for the convenience of large families that, 
for the most part, had no other room to reside in. The 
heat and noise of these apartments, the want of ventilation, 
the constant succession of visitors to the sick persons, the 
pernicious custom of taking strong drinks and flesh diet, in 
utter disregard of professional admonitions, seemed to me, 
forsometime,sufficientcausesforthe production of this fever; 
but its frequent occurrence seriously awakened my atten- 
tion, and led me to discover that the causes above enumer- 
ated generally acted only as predisposing ones, and that the 
disease was excited and kept up by an infectious matter. 
It is customary among the lower and middle ranks of peo- 
ple to make frequent personal visits to puerperal women 
resident in the same neighbourhood, and I have ample evi- 
dence for affirming, that the infection of the disease was 
often carried about in that manner ; and, however painful 
to my feelings, I must in candour declare, that it is very 
probable the contagion was conveyed, in some instances, 
by myself, though I took every possible care to prevent 
such a thing from happening, the moment I ascertained 
that the distemper was infectious. 

The puerperal fever has at length disappeared from my 
practice, and while I have deeply to lament the loss of four 
patients by it, yet I feel greatly consoled in reflecting, that 
its occurrence has led to practical results, which will most 
materially lessen its fatality in future. 



i 



APPENDIX, I. 97 

As I understand that you have, in several parts of your 
work, very particularly illustrated the combined powers of 
copious blood-letting and purging, I shall select two cases, 
to shew the efficacy of blood-letting, purging, and vomiting, 
used in quick succession, and conclude with some desultory 
observations. 

Martha Watson, an unmarried woman, aged nineteen 
years, was delivered of her first child on the 31st of last 
July. Nothing unusual occurred either during or after the 
labour. This woman was healthy and robust, and of a pas- 
sive disposition, and did not seem to feel the peculiar deli- 
cacy of her situation, with that regret and anxiety which is 
so often observed tinder similar circumstances. 

No symptom of disease manifested itself till the 2d of 
August, the third day after her delivery, when she was at- 
tacked with rigors, which were soon succeeded by severe 
pain in the abdomen, considerable febrile excitement, nau- 
sea, and vomiting. These symptoms continued to advance 
with increasing violence, but, notwithstanding, I did not 
receive the least intimation of the indisposition of this poor 
woman until the disease had existed fully thirty hours. 

At nine o'clock of the evening of the 4th, I found her in 
great agony, complaining of a constant pain and burning 
heat in the belly, the surface of which was extremely sore, 
and there was, likewise, much abdominal tension. The 
skin was uncommonly hot and dry, the tongue foul and 
parched, the lochial discharge suppressed, the secretion of 
the milk much diminished, the breathing quick and labori- 
ous, the pulse 136 in a minute, and besides, there was in- 
cessant thirst, and constant nausea or vomiting. 

Although, as previously stated, thirty hours had elapsed 
from the first attack, the urgency of the inflammatory symp- 
toms induced me, even at this advanced period of the first 
stage, to use the lancet; and, accordingly, I took away 
twenty ounces of blood from a large orifice at the arm; 
which brought on some degree offaintness; immediately 
exhibited half a drachm of calomel in mucilage of gum ara- 
bic, ordered three drachms of sulphate of magnesia to be 
taken every hour, in a little gruel, until (ree and repeated 
fecal evacuations were obtained, and recommended the 
diet to be weak tea and thin gruel. 

14 




APPENDIX, I. 

At five o'clock on the following morning, I made another 
visit, and found, that the patient had been purged copious- 
ly upwards of twelve times by the medicines prescribed. 
The nausea and sickness had entirely ceased, and the in- 
tense pain subsided from the abdomen, which, however, 
was still very tender upon pressure. The thirst and other 
febrile sympstoms were nearly the same as before, except- 
ing that the pulse was softer. One grain of tartarised an- 
timony was ordered to be given ever hour until considera- 
ble nausea or vomiting supervened. No alteration was 
made in the diet. 

Calling again about noon of the same day, I was inform- 
ed that four grains of the antimony had been taken as di- 
rected, that full and frequent vomiting had been induced, 
and several liquid stools discharged. There w r as consid- 
erably less tenderness over the abdomen, and the pulse re- 
duced to 126 in a minute. The sickness having quite 
abated, half an ounce of castor oil was prescribed, and the 
same quantity ordered to be repeated two hours after- 
wards. 

By the evening, five more fecal evacuations had taken 
place, and there was then only a slight degree of tender- 
ness remaining over the abdomen ; the skin was warm and 
perspiring freely, and the pulse only 1 16 in a minute. The 
lochia had returned in considerably quantity, and was ex- 
tremely offensive. 

Forty drops of the tincture of opium were exhibited m 
the form of a draught, which gave some hours of refresh- 
ing sleep ; and on the ensuing morning, the 6th of August, 
the patient might be pronounced convalescent ; the pulse 
being very soft, and less than 100 in the minute. Gentle 
laxative medicines, however, were frequently repeated 
till the 10th, after which she very speedily recovered her 
her strength. 

Mrs. D was delivered of her first child, after a se- 
vere labour, on the 15th of August. Every thing went on 
well till the 17th, in the morning of which day she had 
rigors ; succeeded by head-ache, nausea, sickness, increas- 
ed heat, thirst, white clammy tongue, a small vibrating 
{mlse, upwards of 120 in a minute, suppressed milk and 
ochia, great internal heat and pain in the cavity of the 
belly, and considerable tenderness of the abdominal inte- 



APPENDIX, I. 99 

garments. The breathing was laborious, the countenance 
anxious, and the natural functions much oppressed. 

Without delay, I took from the arm twenty ounces of 
blood, prescribed half a drachm of calomel, and small do- 
ses of sulphate of magnesia, and a spare diet, as in the for- 
mer case. 

Before night the patient was purged about ten times ve- 
ry copiously, and she experienced great relief. One grain 
of tartarised antimony was ordered every hour until it ex- 
- cited nausea or vomiting. 

On the following morning, I found that the antimony had 
caused vomiting when the third dose had been taken, and 
that three motions by the bowels had occurred during the 
night. A complete remission was effected, the pain and 
tenderness quite removed from the abdomen, and the pulse 
soft and only 90 in a minute. 

From the 19th till the 23d of August, this patient con- 
tinued better, hardly any medicine except gentle laxatives, 
being required. In the morning of the last mentioned day, 
however, she again became feverish, and the pulse, in a 
few hours, rose to 130 in a minute; and she was afflicted 
with constant and excessive pain in the abdomen. A scru- 
ple of calomel was ordered to be taken directly, and the 
belly to be frequently fomented with flannels wrung out of 
hot water. 

The calomel did not operate, and at six o'clock in the 
evening the pain in the bowels was extremely urgent, the 
abdomen tense and very tender, the skin intensely hot, and 
the pulse small and 160 in a minute. Conceiving that a 
repetition of bleeding was now contra-indicated, 1 ordered 
half a drachm of calomel to be exhibited immediately, and 
half an ounce of castor oil every hour afterwards until it 
operated freely on the bowels. 

At a very early hour in the morning of the 24th I visited 
this patient, and was much gratified to find that the calo- 
mel, and four doses of the castor oil had caused eleven dark 
coloured stools, and produced a remission of all the urgent 
sypmptoms, and a return of the lochia. The pulse was 140 
in a minute, and some degree of abdominal tenderness still 
remained. A grain of tartarised antimony was given every 
hour, and, after having been repeated three times, it oc- 
casioned free vomiting. 



100 APPENDIX, I. 

At night the pulse was reduced to 118 in a minute, the 
skin was warm, and in a state of free perspiration, and the 
abdominal tenderness removed. The sickness had quite 
abaied, and five or six more fecal evacuations had taken 
place in the course of the day. With a view to procure 
rest, an enema, which contained 120 drops of the tincture 
of opium, was administered. 

The patient hati a good night, and next morning was in 
ever) respect convalescent, but notwithstanding, her bow- 
els were kept in a lax state for several succeeding days by 
small doses of castor oil ; and an opiate was occasionally 
prescribed for the purpose of allaying irritation. 

The last case manifests the necessity of constant vigil- 
ance on the part of the practitioner, even when a remission 
has been effected, and shews that however desperate the 
circumstances may be they are not always absolutely insur- 
mountable. If diffusive stimuli had been resorted to, under 
an idea of sustaining the apparently sinking powers of the 
system, 1 have not the least doubt but that the patient 
would have been lost. Evacuations saved her, because 
they removed the inflammation which was verging towards 
a fatal crisis, by oppressing and impeding the vital func- 
tions. 

From long experience, Denman advises antimonial 
emetics, which have, nevertheless, been prohibited in pu- 
erperal fever by some later systematic writers, hardly any 
of whom, however, appear to reason from facts ; and the 
greater part raise objections to tlje use of emetics, merely 
because they cannot perceive in what manner such reme- 
dies can be of service. Without speculating on the subject, 
it is enough for me, that I have seen them really beneficial 
after bleeding and purging; nor shall I attempt to explain 
their mode of operation, although I must confess that they 
have always seemed to produce their good effects by reduc- 
ing the morbid force of the arterial system. 

My attention was particularly turned to the usefulness of 
emetics from an accidental occurrence in a case, in which 
purgative medicines had been given to a considerable ex- 
tent, without completely relieving the pain and tenderness 
of the abdomen; which, however, were soon removed by 
free vomiting, occasioned by a large dose of calomel com- 
bined with jalap. And from that period I have repeatedly 



APPENDIX, I. 101 

used antimonials, with the intention of exciting nausea or 
vomiting, when bleeding and purging, or when purging 
alone, had been premised. 

The forty cases of puerperal fever, which took place in 
my practice this year, were treated by the antiphlogistic 
method ; a few cases by purging simply, and all the re- 
mainer by bleeding and purging, or by bleeding, purging, 
and vomiting, used in the manner previously specified. 

From remarks, diligently made at different time? and oc- 
casions, lhave long believed, that the simple peritonitis of 
child- bed women is nothing more or less than a variety of 
the low infectious puerperal fever, and that they ought to 
be classed and treated as the same disease. My whole 
experience, in an extensive practice of midwifery in the 
middling and inferior classes of society, and more partic- 
ularly that of the last ten months, has left me withaut a 
doubt upon this point. 

The generality of the cases which fell under my care, 
in the present year, were attended by as great apparent 
lassitude and prostration of strength as ever I beheld in the 
common typhus gravior ; but, conceiving that an acute 
local inflammation was going forward in a vital part, I was 
induced to place my sole reliance upon depletion, which, 
when very freely employed in the beginning of the disease, 
never failed to answer my utmost expectations. 

Bleeding may always be employed in the first stage of 
puerperal fever with much benefit, and 1 believe that it has 
been brought into disrepute from having been used indis- 
criminately during the course of the disease. 

From the rapid progress which this fever generally makes, 
the necessity of procuring as speedy a resolution as possi- 
ble will be admitted at once ; and, I conceive, that large 
doses of calomel are admirably calculated, in part, to fulfil 
that intention ; they have been given in a great number of 
instances, and none but the most salutary effects have ever 
resulted from their exhibition, and I can, therefore, confi- 
dently recommend them. 

After what you have written, it would be needless for me 
to enter more into details than I have already done ; par- 
ticularly as my chief object in addressing you at all, is rath- 
er to confirm the accuracy of your statoments, than to offer 



102 APPENDIX, I. 

any additional matter upon the subject that you have dis- 
cussed. 

I took short, but correct, notes of most of the cases of 
puerperal fever as they occurred : if these should be of the 
least use to you hereafter, they are perfectly at your com- 
mand for publication : and I consider you fully entitled to 
all the facilities that I can give to your undertaking, on 
account of the unwearied attention you paid to many of my 
patients, who were afflicted with puerperal fever. 
I am, Sir, 

Your obedient servant, 

J, T. Gregson. 
To John Armstrong, M. D. 



Letter on the same Subject, addressed to the Author, by R* 
Gregory, Esq. Surgeon in Monk- Wearmouth. 

Monkwearmouth, Nov. 3, 1813. 
Sir, 

While acting as an assistant to Mr. Gregson, I witnessed, 
at different times in the current year, at least twenty cases 
of puerperal fever, which were forcibly characterised by 
great abdominal pain and tenderness, unusual celerity of 
pulse, high pyrexia, suppressed or diminished lochia and 
milk ; and also by excessive debility and restlessness, such 
as attend the most severe kinds of typhus. 

From all that I observed I was firmly convinced, that 
the fever was highly inflammatory in the beginning, and 
required the most rigid antiphlogistic practice. Every 
case that I saw more completely satisfied me of the superi- 
ority of the treatment made use of by you and Mr. Greg- 
son. 

With two exceptions only, the cases that I witness- 
ed were treated by free venesection, large doses of calomel, 
and other purgatives ; or by venesection and cathartics, 
with antimonial emetics ; and though prentiful bleeding and 
purging certainly fulfiled every intention, yet antimonials 
seemed to me auxiliary remedies of considerable force in 
promoting a speedy resolution of the disease. Where an- 



APPENDIX, I. 103 

timony excited vomiting, soon after free blood-letting and 
purging, I remarked that the complaint terminated sooner 
than in those cases where it only induced nausea. 

The pain was mitigated, in every instance, by blood-let- 
ting, but permanent relief was not obtained in any case 
until the bowels were freely moved ; and calomel, exhibited 
in doses of a scruple or half a drachm, answered that pur- 
pose extremely well, with the assistance of sulphate of 
magnesia or castor oil. Some practitioners will probably 
think such a quantity of calomel given at one time rather 
hazardous, particularly to a woman labouring under puerpe- 
ral fever ; but a little experience will soon remove their 
groundless apprehensions, and convince them, of its inesti- 
mable value in this disease. 

In no case whatever have I seen the smallest danger 
result from the use of such an unusual dose as above stated; 
on the contrary, it has always been most eminently benefi- 
cial, and the only inconvenience that can atise from its ex- 
hibition is an occasional ptyalism ; yet this, in my opinion, is 
a very desirable occurrence, as the symptoms of the dis- 
ease very rapidly receded in those cases where it took place, 
from the repetitions of the large dose of calomel. 

In the unavoidable absence of Mr. Gregson, some cases 
were left to my own management ; and I made a point of 
bleeding till the patient was likely to faint; a circumstance 
which, I conceive, is of some consequence in checking the 
inflammatory action. It likewise appeared to me, that half a 
drachm of calomel answered better than a scruple, because 
it acted much sooner and more effectually. 

These are the principal facts that occur to me at present, 
which I hope you will find sufficient, as evidence of the 
success of your plan of treatment. From the notes in my 
possession, it would have been easy for me to have given 
you a minute detail of several cases, but having been 
informed by Mr. Gregson that he has addressed you at some 
length upon the subject, I have thought it better to be as 
brief as possible. 

I remain, sir, 

Your very obedient servant, 

R. Gregory. 

T# iTikn Armstrong, M. D. 



104 APPENDIX,!. 



Letter addressed to the Author, by J. Wolfe, Esq. Surgeon 
in Chester~le- street, near Durham. 

Chester-le-street, Aug. 4, 1813. 
Dear Sir, 

In reply to your inquiries, 1 beg to inform you, that since 
last January several cases of puerperal fever have fallen 
under my observation, but none of them were so severe as 
the case of the lady whom you lately attended with me in 
the neighbourhood of Chester-le-street. Since you appear 
to wish me to give you some account of my general me- 
thod of treatment, rather than details of particular circum- 
stances, I shall endeavour to comply with your request in 
as few words as may be. 

Whenever I find that any patient after her labour has a 
very quick pulse, hot skin, thirst, oppression, abdominal 
pain and tendefness, I immediately open her bowels freely 
with calomel, castor oil, or infusion of senna, and occasion- 
ally assist the operations of these medicines by a cathartic 
enema, to procure speedy evacuations. If, after the con- 
tents of the lower part of the bowels have been dislodged, 
the stools are of a dark brown colour, resembling coffee- 
grounds, very copious, of the consistence of thick gruel, 
and of a fetid smell, I am led to suspect the existence of 
puerperal fever, and continue the laxative medicines in 
order to obtain several free stools daily, till the peritoneal 
pain and tenderness are considerably abated, and the pulse 
diminished in frequency ; occasionally, however, I pre- 
scribe an anodyne draught at bed time, or an anodyne injec- 
tion, to suspend the action of the intestines and procure 
some ease and rest. 

During the last sixteen years, I have always trusted to 
very copious purging for the cure of puerperal fever, and 
to effect my purpose have often been obliged to keep the 
bowels very tree for several days successively, and in some 
severe cases, even for two or three weeks before the symp- 
toms of the abdominal inflammation have completely sub- 
sided. In short, I am never afraid of my patients having 
too many stools, as long as abdominal pain and tenderness. 



APPENDIX, I. 105 

and fever continue. When I examine the alvine discharge, 
I do not expect to find ordinary stools, but evacuations of a 
peculiar nature, and am often obliged to explain this matter 
to nurses, who are in general greatly alarmed at so much 
purging. 

From the commencement of the complaint to its ter- 
mination, I have almost always observed, that the stools 
have not had a natural appearance, and frequently that 
hard scybala have only been discharged when the stools 
were becoming natural towards the end of the disease. As 
it has always been my custom to inspect the evacuations, I 
know from experience that I can detect the presence of pu- 
erperal fever, by their appearance and consistence, taken 
in conjunction with other symptoms described in the former 
part of this letter. 

Having been accustomed to treat the puerperal fever 
solely by active purging, I can speak decisively in favour 
of that mode of practice ; nor do I recollect that I ever 
made use of the lancet, except in one case attended with 
symptoms of acute hepatitis, in which plentiful bleeding 
from the arm produced a remarkably good effect. 

It has sometimes happened in my practice that one 
brisk purge only has been necessary in the beginning of the 
complaint; but in those cases the free evacuation of the 
unnatural stools went on for several days, and, like a kind 
of spontaneous diarrhoea, carried off the disease. 

Though I said above that I treated the complaint solely 
by purging, yet I do not omit to give the saline mixture in 
the state of effervescence, when sickness or vomiting take 
place, and afterwards continue it as a febrifuge. 

The late Dr. Clarke of Newcastle relied entirely upon 
the purgative plan of treatment, and I freely acknowledge 
that I first made use of it at his recommendation, having 
had the good fortune to attend a patient labouring under 
puerperal fever with him, at the commencement of my ob- 
stetric practice. 

My practice in puerperal fever has been generally sue- 
cessful, but, as I always see my patients very often after 
their delivery, I have had it in my power to combat the 
disease in its first attack ; which circumstance gives the 
practitioner great advantage, and to which 1 am partly in- 

15 



106 APPENDIX, L 

clined to ascribe the fortunate result of the cases that have 
come under my care, 

I am, dear sir, 

Yours, very truly, 

John Wolfe. 
To John Armstrong, M. D. 



Observations on the state of the Atmosphere between January 
and October, 1813, the term in which the Puerperal Fever 
was most prevalent* 

The following brief account of the weather is extracted 
from the diary of an acquaintance ; and the author regrets 
that it contains no barometrical and thermometrical ob- 
servations. One of the principal reasons for inserting it is, 
that the puerperal fever prevailed in different places during 
the same period. 

In the beginning of January, the weather was very mild 
and clear, with light airs from the west and south-west ; 
about the middle, there was a strong frost, with some snow ; 
and the day afterwards, heavy rain, the wind blowing from 
the south-east; from the 16th to the end, it was mostly 
clear and frosty ; very little snow fell, and the wind varied 
from the south, west, and north. The complaints most 
prevalent in Sunderland in this month were low fevers, 
rheumatism, and dyspepsia. 

February was ushered in by fresh breezes from the west 
and south-west, and continued, for the most part, fair till 
the 10th, when hard squalls came on from the west-south- 
west, with showers of rain, sleet, and snow ; from the 11th 
onward, there were strong gales from the south, and west, 
and frequent heavy rains. Low fevers were rather more 
prevalent this month, and the number of rheumatic and 
dyspeptic cases were nearly the same as in the last. 

March was remarkably mild and clear for the season ; 
very little rain fell, and the wind was light and variable ; 
it shifted chiefly frem the west to the west-north-west 
throughout the month. Low fevers almost entirely disap- 



APPENDIX, L 107 

peared, though rheumatic and dyspeptic complaints were 
nearly as numerous as before. 

From the 1st of April to the 5th the wind blew fiom the 
west-south-west or from the east north-east, much snow 
and sleet fell, and it was intensely cold ; from the 10th to 
the 21st the wind was almost constantly in the west ; the 
weather was fine and dry, and the early blossoms were ad- 
vanced more than is usual at the season. From about the 
22d to the end of the month, high gales from the east- 
north-east and north-east, with rain, sieet, and snow, which 
did much injury to the fruit-trees. In this month a few 
eases of low fever again occurred, hardly any of rheuma- 
tism, or dyspepsia, but some of catarrh. 

The commencement of May was rainy and very cold, 
and the wind continued in the north-east or south-east till 
about the middle, when it changed to the south-west, and 
some rain and thunder followed; from the 16th it blew 
from the south-east ; and the weather was very wet and 
hazy till the 25th, on which day it became warm and dry, 
and continued so till the end of the month. 

The long continuance of the cold east winds destroyed 
almost all the early blossoms ; and the sides of those hedges 
and trees which were exposed to its successive blasts ap- 
peared as if they had been scorched, exhibiting such ef- 
fects as are attributed to the Siroc in Sicily. In this month 
there were some low fevers, and rheumatic complaints, and 
several dyspeptic and pulmonic cases. 

The weather was alternately warm and cold till the 6th 
of June, during which some rain fell, and the wind was 
principally from the north-east ; from this time there were 
light south-east breezes, with very mild weather till the 
1 lth ; after which it became for a short time rather thick 
and hazy, the wind blowing from the south-west. From 
about the 16th to the end of the month it continued cold 
and hazy for the season, and the wind veered from the 
north-east to the south-east. In the beginning of July, 
there were strong gales from the east-south-east and north- 
north-west, with rain, followed by some tolerably calm 
clear days, with fresh gales from the north and south-east. 
From the 16th to the 20th, the wind was principally in the 
west, and there was a good deal of rain, though the weather 
upon the whole was very sultry. One or two cold days af- 



IpS APPENDIX, I. 

ierwards occurred with a north-east wind ; but the weather 
again became sultry, and there was much thunder, light- 
ning, and rain, the wind blowing either from the south- 
west or south-east. During these two months, low fe- 
brile, rheumatic, and dyspeptic complaints were still most 
prevalent, and there were some cases of catarrh and dys- 
entery. 

From the 1st to the 9th of August, the wind was from the 
south-west and north-west, the weather fine, and some light 
showers of rain ; from the 9th to the 12th, the wind shifted 
from the west north-west to the north and south-west, and 
the atmosphere was clear and sultry ; from the 13th to the 
20th, fresh gales from the north-west and west, and occa- 
sional showers of rain ; from the 21st to the 26th, fine, 
calm, clear weather, and the w r ind in the north-east and 
south-east ; from that time till the end of the month, it 
mostly blew from the north-east ; there was very little 
rain, the air cloudy and rather cold for the season. There 
were several cases of typhus this month, some of scarlet 
fever, dysentery, rheumatism, enteritis, and cholera. 

From the 1st of September to the ^?th, the atmosphere 
was sometimes hazy, and sometimes clear ; light airs from 
the south-west, with slight showers ; from the 7th to the 
12th, the wind shifted from the west-south-west, north- 
west, and north-east ; some rain fell, and the weather was 
alternately fair and cloudy; from the 1:3th to the 16th, 
strong gales from the west-south-west, cloudy and rather 
rainy ; from that time to the 20th, the wind was variable, 
with fine, clear weather ; from the 20th to the 29th, it was 
in the north east and north, and the air cloudy and cold; 
on the 30th, fresh breezes from the east-south-east, and 
the day was warm and clear. The diseases which pre- 
vailed most this month were typhus, scarlet fever, rheuma- 
tism, dyspepsia, and pneumonia. 

As no evident connexion could be traced between the 
variations of the weather, and the increase and decrease of 
the puerperal fever, it has been thought unnecessary to 
state the number of cases which occurred in each month. 



APPENDIX, No. II. 



Letter from Dr. Joseph Clarke to the Author, containing 
Remarks on some Parts of the First Edition of this Work* 

Dublin, Oct. 19, 1818. 
Sir, 

In the 9th page of your preface to " Facts and Observa- 
tions on Puerperal Fever," you have invited practitioners 
to liberal criticism. I embrace therefore the opportunity 
of a second edition, about to appear, to submit a few facts 
on this subject to your notice. 

Very serious difficulties appear to me to arise from the 
first paragraph of your preface, stating that " in the follow- 
ing work both the ordinary peritoneal inflammation, and 
the low malignant fever are comprehended, under the 
common term of puerperal fever." That the same meth- 
od of cure may apply to each, I am bound to admit on 
your authority. But after more than thirty-five years* 
close connexion with the Lying-in-Hospital of Dublin, one 
of the largest in Europe, and during the same period hav- 
ing been busily employed in private practice through this 
city, the population of which considerably exceeds 200,000, 
I am enabled to declare that common peritoneal inflamma- 
tion is familiar and well known to me, especially in hos- 
pital practice, whereas the low malignant fever as describ- 
ed by you and my late friend Dr. John Clarke is nearly 
unknown to me, and has rarely occurred among that class 
of patients by whom 1 am employed. Classing these two 
diseases together has, in my mind, led you into an asser- 
tion very alarming both to practitioners in midwifery and 
to their patients, viz. that there is reason to apprehend the 
former may be the medium of conveying infection to the 
latter. That such is not the fact respecting the common 
peritoneal inflammation, I do most positively affirm. Dur- 
ing the prevalence of this disease in the Dublin hospital, in 



110 APPENDIX, II. 

the years 1787 and 1738, (for which, see Edinburgh Medi- 
cal Commentaries, vol. xv.) no such disease prevailed in 
the town. Not one case occurred to me, who had the 
principal care of the hospital, nor to any person connected 
with it. 

The same may be also affirmed of the year 1813, when 
a great deal of peritoneal inflammation was observed in the 
hospital, but none whatever in the upper classes of society 
in town. In truth if I might presume to form a judgment, 
from the most respectable accounts of epidemical diseases 
prevailing among lying-in-women, both in London and va- 
rious other parts of England, I should be obliged to declare 
that Dublin for the last thirty-five years has been peculiar- 
ly favoured, no malignant low fever having at any time 
prevailed among the upper ranks. In peritoneal inflamma- 
tion we have observed almost no delirium, no low mutter- 
ings, no petechias These, I apprehend, are symptoms 
applicable peculiarly to the low malignant fever. 

In the treatment of peritoneal inflammation, having seen 
many severe threatenings of this disease yield to brisk purg- 
ing alone, I should incline to delay blood-letting for a few 
hours, until the effects of the first measure were clearly 
ascertained, and I see no objection whatever to a large 
dose of calomel to make a commencement of brisk purga- 
tion. When the stomach proves very irritable, and the 
bowels difficult to be moved, experience has taught me that 
a large bleeding is a wise measure. When the passage 
through the bowels have been several times very freely ef- 
fected, infusions of senna with neutral salts and tincture of 
senna, castor oil, and tartrate of kali and soda in a saturat- 
ed saline mixture, may be very beneficially used to keep up 
the action of the bowels, day after day, till the soreness of 
the abdomen and fever abate. W r arm fomentations to the 
abdomen seldom fail to be agreeable to the patient, and to 
abate pain. When venesection fails to relieve abdominal 
distress, my friend, Doctor Labatt, the present Master of 
our Lying-in Hospital, has found great relief from the ap- 
plication of two or three dozen leeches to the abdomen, 
and persevering in stupes, after they have fallen off. From 
Dr. Labatt I have obtained the following important remarks 
on some parts of your practice. 



APPENDIX, II. Ill 

" So.on after the publication of Dr. Armstrong's work on 
Puerperal Fever, I was led to exhibit calomel in large 
doses (3 1 to 3ss.) in peritonitis. My first trials were at- 
tended with success. Subsequent experience however 
convinced me that it was safer and better to administer it in 
smaller doses, combined with some other purgative. The 
combination I have found to succeed best is ten or twelve 
grains of calomel, with an equal quantity of jalap, and a few 
grains of ginger : this when followed by a dose of castor 
oil, or a few spoonfulls of the infusion of senna made active 
by tincture of jalap and Epsom salts, will seldom fail to pro- 
duce a speedy and complete evacuation of the bowels. Cal- 
omel in large doses sometimes produces alarming weakness, 
a tympanic state of the abdomen, with vomitings and great 
irritability of stomach, which prevent for some time the ex- 
hibition of any purgative by the month." 

During the great prevalence of peritonitis in our hospi- 
tal in L813, I was very frequently consulted. The stomach 
showed most unusual irritability, and the bowels greater 
reluctance to yield to purgatives than I had ever before 
witnessed. In addition to the usual routine of practice, 
numerous trials were made of the rectified oil of turpentine, 
in doses of from six to eight drachms, sometimes in plain 
water, sometimes combined with an equal quantity of cas- 
tor oil. The first few doses were generally agreeable to 
the patient and seemed to alleviate pain. By a few repe- 
titions it became extremely nauseous, and several patients 
declared u they would rather die than repeat the dose." 
In more than twenty trials of this kind, not a single patient 
recovered. In a few cases as an external rubefacient, oil 
of turpentine, sprinkled on hot flannel and applied to the 
abdomen, has afforded remarkable alleviation of pain. 
When the abdomen becomes tympanic, towards the de- 
cline of peritonitis, two or three drachms of oil of turpen- 
tine combined with a dose of castor oil will frequently 
diminish the abdominal tumefaction in a most satisfactory 
manner. It does not however always ensure recovery. 

I must trust to your love of truth, and desire to be 
useful, for excusing the freedom with which I have ven- 
tured briefly to submit these facts and observations, and 
beg to assure you most respectfully of my best regards. 

Joseph Clarke, M. D. 

44, Rutland Square. 



112 



APPENDIX, II. 



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APPENDIX, II. 115 



Letter respecting the Puerperal Fever from Thomas Alcock. 
Esq. Member of the Royal College of Surgeons, and Ac- 
coucheur to St. Jameses Infirmary. 

4, Piccadilly, Dec. 1818. 
Dear Sir, 

In answer to your inquiry respecting the appearance ot 
puerperal fever, I subjoin the following general remarks, 
which, if you consider them of sufficient interest to appear 
in your valuable work, are much at your service. 

Within the last three months, in the course of my public 
and private practice, several cases of illness after parturi- 
tion have occurred, which generally speaking might be 
called puerperal fever ; but if to fever we annex the idea 
of increased heat, the name would not correctly apply to 
each particular instance. Perhaps the term puerperal fe- 
ver may be somewhat too indiscriminately used, and some- 
times without any definite signification. It has been doubted 
whether any idiopathic fever exist, peculiar to the puerpe- 
ral state ; and as far as my observation has extended, the 
symptoms of fever have for the most part appeared rather 
to be symptomatic of inflammation in some internal organ, 
and have yielded to proper treatment much more speedily 
than idiopathic fevers. 

If the greater part of the various complaints which wo- 
men in child-bed suffer are in reality inflammations of the 
uterus, of the intestines, of the peritoneum, &c. would not 
the pathology and treatment be equally clear in designa- 
ting the disease by its appropriate name, as by calling it 
puerperal fever, and considering the essential or pathog- 
nomonic derangement as a mere symptom? Doubtless idio- 
pathic fever may take place after child-birth as well as un- 
der other circumstances ; but I am persuaded it is of much 
less frequent occurrence than the inflammations of the sev- 
eral viscera. 

Of the cases which have occurred lately, call them by 
what name you please, the symptoms were very various, 
though mostly indicative of inflammation, and affecting the 
abdominal and pelvic more frequently than the other vis- 
cera : in some the pain and tenderness of the abdomen 
and hypogastrium were distinct and well marked, in some 



116 APPENDIX, II. 

obscure. Not unfrequently the pains were referred to the 
back and loins, extending down the thighs ;* in others the 
principal seat of the disease was confined chiefly to the 
chest, and in a few the head appeared most affected. In 
some the chest and abdomen suffered simultaneously. In 
several instances there was extreme depression of mind* 
The tongue was generally foul, but moist, sometimes a dry 
brown streak in the centre, the edges remaining moist. 
There was loss of appetite. The bowels were costive till 
purgatives were administered, and the excretions were fre- 
quently dark and unnatural, till the evacuations became 
copious. The urine was frequently turbid : the lochia and 
milk were often suppressed or much diminished in quanti- 
ty ;; in some cases the loehial discbarge assumed a puriform 
appearance. The recurrence of a sanguineous discharge, 
in the course of the illness, was mostly a favourable symp- 
tom* The skin at first was usually dry, but generally be- 
came relaxed after depletion had been used ; its tempera- 
ture varied considerably. However various the apparent 
seat of the disease, the cases all agree in one leading cir- 
cumstance, namely, in great derangement of the sanguife- 
rous system. The pulse, though sometimes slow before 
the patient began to complain, was generally much in- 
creased in frequency, sometimes from 120, 130, or 140 in 
the minute to a rapidity not distinctly to be counted : its 
fulness, hardness or softness varied so much in different ca- 

* It may seem superfluous to mention that, during the first days after 
delivery, the vague accounts of some patients might lead to the mistaking 
of after-pains for those of inflammation. When, as sometimts happens, 
coagulum has formed in the uterus, after the expulsion of the placenta, 
the distinction will require close attention, as the intermissions of pain are 
less distinct. But in mere after pains the position of the patient is usu- 
ally upon the side, the motions of the lower limbs are made without much 
precaution, and though on sudden pressure upon the uterus she complains 
loudly of pain, yet if the pressure be gradually made, and her attention be 
directed to another subject, it may be very firmly made without any pain- 
ful expression of countenance. Whilst in inflammation of the uterus or 
its appendages the patient almost always takes great precaution in every 
motion of the trunk or lower limbs; a peculiar though sometimes slight 
anxiety of countenance exists, grtfatly increased on pressure upon the af- 
fected part, however gradually made, or Whatever attempt to divert her 
attention at the moment; there is no perfect intermission of pain. In the 
spasmodic pains the pulse is but little quickened — in the inflammatory its 
frequency is generally much increased. — The uneasiness arising from a 
distended bladder cannot be mistaken by any attentive practitioner, 
although I have known this symptom greatly everlooked. 



APPENDIX, II. 117 

ses, and even in the progress of the same case, that, as in 
other acute diseases, to have depended on it as a guide 
would have been fallacious, The pulse, considered with 
reference to the state of the organs and functions of the 
body, is a valuable aid ; but is much less to be depended 
on than the concurrence of other pathognomonic symp- 
toms. 

The period of attack was irregular, but generally from 
the second to the seventh day ; though I have witnessed 
clearly marked symptoms of inflammation of the uterus and 
abdominal viscera before delivery, particularly in those ad- 
vanced in years at the first labour. In a considerable pro- 
portion there were distinct rigors succeeded by heat and 
re-action \ in others no rigor or chilliness was observed. 

In some of the milder cases the exhibition of an emetic, 
given in nauseating doses, and increased till vomiting was 
produced, and subsequently given at longer intervals till 
the bowels were purged, relieved so much as to render the 
use of the lancet unnecessary ; but in the more severe ca- 
ses, with some exceptions, bleeding was required and was 
performed with evident relief. Sometimes the depression 
of all the vital powers is so sudden and overwhelming that 
depletion cannot be used with a rational prospect oi bene- 
fit to the patient. Indeed the attack is sometimes so sub- 
duing as almost to preclude the hope of recovery under 
any mode of treatment. Neither are those cases where 
acute pain exists the most to be feared. Whoever has 
watched the progress of disease in its worst form in the 
puerperal state, may have observed the approach of death 
depicted in the countenance of the sufferer, where every 
answer to the inquiry if there existed any pain, has been in 
purport, " No,— no pain ; but so weak." Nor is this state 
the mere termination of painful symptoms by mortification 
described by authors ; it does sometimes occur without any 
pain during its progress, which in this form is usually of 
short duration. Blood taken from a vein under such cir- 
cumstances has afforded no relief, nor has it coagulated as 
is usual ; but the red particles settling to the bottom, have 
left the surface like thin size or extremely weak jelly. 

The value of blood-letting, however, is inestimable in 
cases where the inflammation of any important organ has 
actually begun, or where the general excitement is so great 



118 APPENDIX, II. 

as to threaten such an occurrence ; and when used early 
and to a sufficient extent, frequently subdues every urgent 
symptom. Sometimes there is no recurrence of the com- 
plaint 5 but where the indications are clear and the relief 
from the first bleeding has been decisive, if symptoms of 
danger return, it is not sufficient that the patient has been 
bled, the operation must be repeated. In all cases the ef- 
fect produced, and not the quantity taken, must be the 
measure of a sufficient bleeding. Sometimes the abstrac- 
tion of a few ounces of blood will induce syncope, and be 
followed by perfect relief; at other times the quantity must 
be large before any obvious effect be produced either on 
the painful symptoms or the pulse. I need not observe, 
that if the blood be taken in a full stream, and, if admissi- 
ble, in the erect or sitting posture, a much less quantity 
will suffice than under an opposite state. 

I would earnestly recommend to those entrusted with 
the care of puerperal patients requiring the use of the lan- 
cet, not to content themselves with directing its use, but to 
see it carried into effect. It is impracticable to determine, 
without reference to the changes which may occur during 
the operation, what quantity shall be just sufficient and in no 
degree excessive ; even the life of a patient may sometimes 
depend on the apparently trifling circumstances of the man- 
ner of performing this simple operation. A timidly made 
puncture, and a small stream, may produce a sufficiency of 
blood to be shown at the next visit of the practitioner, but 
without affording any relief; w r hilst a much less quantity 
taken freely will not only relieve, but, by the appearance 
of the blood, will either confirm the treatment or afford 
useful indications for the further management of the case. 

Purging will be found a valuable auxiliary, but as far as 
my observation has extended, I have not witnessed so much 
relief from drastic as from mild evacuants. Some cases, 
from the extreme torpor of the bowels, require the more 
drastic preparations and in liberal doses, which in a state 
of health the patient would be unable to bear ; but 1 have 
often remarked that those cases in which the purging was 
excessive, whether it occurred spontaneously or succeeded 
the exhibition of strong medicines, were less manageable 



APPENDIX, II. 119 

than others, and when recovery took place it was much 
more tardy than under other circumstances. 

The well known relation between the general surface 
and the internal organs will suggest principles of treatment, 
which the attentive practitioner will appreciate and readily 
carry into effect. The warm bath, though a valuable ad- 
junct on some occasions, is attended with too much fatigue 
to the patient to be frequently employed. I have used 
with evident relief fomentations to the abdomen and the 
whole of the lower extremities, which may be effected with- 
out fatigue, and may be longer continued or oftener repeat- 
ed than the bath. The necessity of regulated diet, tempe- 
rature and general management will be obvious. 

From the preceding observations it will readily be infer- 
red, that as the seat of the diseases occurring in puerperal 
patients has varied, so also have the morbid appearances 
discovered after death. The brain has been found exces- 
sively loaded with dark blood, as have been the lungs, 
whilst the secretion from the mucous membrane of the tra- 
chea and bronchia, which was much increased in vascu- 
larity, has been so copious as to produce death by suffoca- 
tion. In such cases the abdominal and pelvic viscera 
exhibited no considerable traces of disease. In some, effused 
serum has been found in the chest, in considerable quanti- 
ty. In others the traces of inflammation of the small in- 
testines and peritoneum have been clear and well marked, 
by adhesions, effusions of coagulable lymph or serum, and 
by great increase of vascularity. Sometimes suppurations 
have been found in the cellular membrane adjoining the 
rectum ; and where the inflammation of the uterus and 
contiguous viscera has been well marked, I have observ- 
ed, in addition to the usual appearance of inflamed intes- 
tines, a quantity of pus in the lower part of the abdomen, 
and in the pelvis surrounding the uterus and appendages. 
Pus in the sinuses of the uterus is not unfrequent : the ap- 
pendages usually correspond to the state of the uterus. 
Though the peritoneal surface of the intestines more fre- 
quently suffers, I have known the contrary happen, and 
whilst the external surface of the intestines scarcely exhib- 
ited any indication of disease, the mucous membrane 
through a great portion of its extent has been inflamed, and 



120 APPENDIX, II. 

in parts proceeding to a state of erosion, but in these cases 
purging had been excessive. 

I remain, 

Dear Sir, 

Yours very truly, 

Thomas Alcock. 

To Dr. Armstrong. 



PRACTICAL ILLUSTRATIONS 



OF THE 



SCARLET FEVER, 

PULMONARY CONSUMPTION, AND 
MEASLES ; 

WITH OBSERVATIONS 

ON THE EFFICACY OF 

SULPHUREOUS WATERS 

IN CHRONIC COMPLAINTS. 



BY JOHN ARMSTRONG, M. D. 

PHYSICIAN TO THE FEVER INSTITUTION OF LONDON. 



THE END OF EVERY THING SHOULD DIRECT THE MEANS. 

William Penn* 



FIRST AMERICAN, FROM THE SECOND LONDON EDITION- 



HARTFORD : 

OLIVER D. COOKE AND SONS, 



1823, 

L > 



IV PREFACE. 



to note the phenomena of disease at the bedside ; and hav- 
ing collected many facts, and deduced many inferences, I 
ventured to publish the results of my experience. New 
editions of my writings having been recently called for, this 
volume has been carefully revised ; and it is hoped that it 
will be found less imperfect than the former edition. In re- 
viewing the history of my own mind, I have found, that one 
of the first steps in the progress of practical knowledge, is, 
to unlearn. But in having freed myself from many errone- 
ous associations of education, I am exceedingly desirous not 
to be entangled in those strong partialities which men are apt 
to entertain for their own productions ; and therefore I shall 
studiously attend to the suggestions of candid criticism, 
whether publicly or privately conveyed, as I trust that my 
sole object is the advancement of that Art, to which so large 
a portion of my life has been devoted. 

Once our libraries were crowded with Commentaries on 
the opinions of others, a state of literature which, when 
general, always marks the declining genius of a country ; 
but now, instead of such servile employment, the press daily 
teems with the productions of those who possess that inde- 
pendence which prompts them to observe and to think for 
themselves. Many of these productions, it is true, may 
bear the evidences of too precipitate an ardour, but still 
they are the earnests of better times and things ; and where 
such numbers continue, to present their offerings, the treas- 
ury of science must be enriched at last. Among these I 
have presumed to appear, conscious that the labour of a 
mind like mine can add but little to the general stock ; yet 
it would be most consolatory to me, if that little should at 
all be found to alleviate human suffering, or to stimulate 
others to more successful exertion. 

23, Southampton Row, Russell- Square, November J 2, 1818. 



CONTENTS. 



SCARLET FEVER. 

Page 

Preface iii 

The Scarlet Fever 1 

Description of the Scarlatina Simplex ... 2 

. — Anginosa ... 4 

three Forms of the Scarlatina Maligna 6 

Treatment of the Scarlatina Simplex ... 20 

. Anginosa ... 24 

Method of treating Suppurations in the internal Ear after 

Scarlet Fever 29 

Treatment of the Scarlatina Maligna . . . 33 

PULMONARY CONSUMPTION. 

Pulmonary Consumption . . . . . 71 

Diseases with which it is liable to be confounded : — 

Chronic Inflammation of the Bronchia ... 72 

Ulceration in the Trachea . . . . . 75 

Chronic Inflammation of the Pleura . . . .78 

Chronic and Common Inflammation of the Lungs . 81 
Causes of Pulmonary Consumption enumerated, and its Pa- 
thology illustrated . . . . . . 87 

Diagnostic Signs . . . . . . .124 

Treatment of Chronic Inflammation of the Bronchia . 127 
Dr. Chapman's Cases of Chronic Inflammation of the Bron- 
chia cured by Bark 132 

Hints on a Method for improving our Materia Medica 134 
Treatment of Ulceration of the Trachea . . .136 

Chronic Inflammation of the Pleura, &c. 140 

Pulmonary Consumption . . 145 

Remarks on Digitalis and Tartarized Antimony . 160 
Proposal to establish a Society for the purpose of further 

elucidating the Nature and Treatment of Phthisis 170 

Dr. Barlow's Remarks on the Use of Flannel . 171 

MEASLES. 

Measles 177 

History and Pathology 178 

Treatment and Sequelae 194 



CONTENTS. 

BALSAM OF COPAIVA. 

Observations on the Efficacy of the Balsam of Co- 
paiva in Inflammations of Mucous Membranes • 3 

SULPHUREOUS WATERS. 

General View of the Pathology and Treatment of 
Chronic Diseases, with Illustrations of the Util- 
ity of Sulphureous Waters . . . . 15 
The Abuse of Opium and Mercury .... 32 
Simple Excitement a State different from Inflammation 77 
Arrangement of the Functions of the Human Body into the 
Vital, the Mechanical, and the Chemical . . 80 



SCARLET FEVER. 



THE SCARLET FEVER. 



THE Scarlatina Simplex, Anginosa, and Maligna, are the 
three species into which most authors have divided this dis- 
ease : and certainly the first of these adjunctive terms is 
sufficiently exact, but the last are objectionable, since they 
do not mark the proper characters of the two remaining 
species. With respect to the epithet Anginosa, it denotes 
a symptom more or less common to all the modifications, 
and therefore cannot be correctly applied to one in partic- 
ular. As for that of Maligna, it expresses nothing distinct 
concerning the nature of the disease, and confounds under 
one species some striking varieties ; while it aiso involves 
an hypothesis as to the presence of something hostile to the 
principle of life, and may thus mislead by its received im- 
port. Yet to avoid innovation, 1 shall adhere to the old 
nomenclature, and, to remove obscurity, shall at the same 
time point out those peculiarities of the complaint not in- 
cluded in our common classifications ; and though little or 
nothing new may be adduced relative to the two first spe- 
cies, it is hoped, that some additional information will be 
communicated on that which is deemed malignant. 

An intelligent writer* has observed, that it is by a clear 
and distinct recapitulation of little circumstances, that or- 
ators, and all those who address the passions, render their 
descriptions more vivid and complete, and interest as well 
as influence the minds of their hearers. Be this as it may, 
it cannot be doubted, that the medical art might often be 
advanced, and humanity benefitted, by authors attending to 
such minutice as mark the similarities, discrepancies, and 
stages of diseases. Under this impression, I shall be rather 

* Letters on Literature, Taste, and Composition. By George Gre- 
gory, D. D. In two Volumes. See vol. i. p. 17, London : printed for 
Richard Phillips. 1808. 

1* 



4 SCARLET FEVER. 

sure to give rise to inflammation there. It is on this ac- 
count, that many diseases, merely marked by simple excite- 
ment at the beginning, are complicated with inflammation 
in their progress ; and hence it is, too, that apparently be- 
nign seizures of scarlatina may eventually become the caus- 
es and concomitants of serious affections of some of the vis- 
cera. Nor is this doctrine to be confined to the scarlet fe- 
ver alone, since it is alike applicable to almost every other 
febrile complaint. It is indeed only in subjects of the sound- 
est constitutions that we ever see simple excitement un- 
combinedly exist throughout a disease ; and the reason why 
it so frequently occasions inflammation is, that some tissue 
or other had been secretly in fault before its occurrence. 
Constitutional shocks are by far the most common causes of 
internal inflammation ; and the precise seat of that inflam- 
mation is determined by some antecedent defect in the or- 
gan attacked. But it is time to pursue the inquiry of the 
scarlet fever. 

SCARLATINA ANGINOSA. 

The Scarlatina Anginosa is more strictly an inflammatory 
form of the disease, and attacks nearly in the same way as 
the simple scarlet fever. But to greater degrees of chilli- 
ness, head-ache, and restlessness, in the first stage, are su- 
peradded a marked oppression of the praecordia, and pros- 
tration of the voluntary powers, with nausea, retching, or 
vomiting. The efflorescence most commonly appears on 
the skin within the first three days from the development 
of the excitement, and about the same time redness and 
swelling are observable on the internal fauces ; the patient 
complains of stiffness in the neck and jaw, and fulness as 
well as soreness in the throat, particularly when he at- 
tempts to speak or to swallow. The pulse is throughout 
quicker than in the simple scarlet fever ; the thirst greater ; 
the tongue drier, and more florid at the edges ; the uneasi- 
ness in the head more distinctly felt ; the stools darker, or 
more morbidly bilious ; the heat of the surface more ele- 
vated, often rising to 106 Q or 108° of Fahrenheit's scale, 
and even sometimes higher. The evening exacerbations 
are also greater, and they often induce a species of deliri- 
um, in which the patient, particularly if left alone, or in the 
dark> talks much to himself. In this modification of the dis- 



SCARLET FEVER. 5 

ease, as in most others, the affection of the throat is de- 
pendant in a great measure upon the fever : if the latter 
should kindly abate, from the first four or five days, there 
will be seldom any sloughs or specks about the tonsils ; but 
merely an increased secretion of mucus, some of which often 
adheres to the part, and looks like an ulcer. But when the 
fever continues longer, or runs higher, specks generally 
form about the tonsils, which are finally converted into su- 
perficial, ash-coloured sloughs. Even when such cases are 
favourable, the throat is loaded w ith a glutinous mucus, and 
the pituitary membrane often much inflamed ; but neither 
the discharge of the throat nor of the nose is of an offensive 
or acrid nature. The superficial sloughs in the throat be- 
gin to separate as the fever declines, which it frequently 
does about the eighth day, and then the sores beneath heal 
rapidly. It sometimes, however, happens that, instead of 
ending so favourably, very dangerous symptoms arise in the 
progress of the fever ; and in most of these examples the 
sloughs grow fouler, and the discharge from them and from 
the nose becomes very acrid. Painful indurations of the 
glands in the neck, tenesmus, or diarrhoea, are then not un- 
common, all of which seem to be connected either with the 
irritation, or with the foul secretions of the fauces. Under 
these circumstances, patients sometimes gradually sink into 
an irrecoverable collapse ; or expire from an attack of bron- 
chial inflammation, or from gangrene of the throat. In oth- 
er unfavourable instances, however, the danger is not con- 
fined about the throat, but rather proceeds from the brain, 
which is sometimes greatly affected in the stage of excite- 
ment ; and the patient at last dies comatose, about the end 
of the second week. Again, in cases of a still different cha- 
racter, where the brain is less seriously disordered, symp- 
toms of abdominal disease arise in the stage of excitement, 
and by degrees become most urgent. At first there are on- 
ly slight pain and soreness in some part of the abdomen, 
with a quickened pulse and respiration ; but the pain and 
soreness gradually increase, and at length are attended with 
vomiting, eructation, fulness of the belly, and general rest- 
lessness. In six, seven, or eight days, the abdominal sore- 
ness and pain abate or disappear, while the pulse grows 
more rapid and feeble ; the breathing more anxious ; and 
the vomiting more urgent. Cold clammy sweats, and an 



S SCARLET FEVER. 

death approaches, there is always, in the beginning of the 
disease, a marked and unequivocal stage of general and 
high excitement, to which the appearances of extreme de- 
bility and putrescency of the last stage may be clearly tra- 
ced as mere consequences* It is this acutely inflammato- 
ry form of the scarlet fever, that Huxham, Heberden, and 
Cullen have denominated the most malignant; their de- 
scriptions distinctly showing, that very great excitement 
existed in the commencement, whatever degrees of putres- 
cency might accompany the close. 

This form of Scarlatina Maligna so far resembles the 
Scarlatina Anginosa from the first, that in both the stage of 
oppression is of an uncertain continuance : sometimes it 
extends to three or four days, at other times occupies a 
shorter, and seldom a much longer term ; but in general, 
the re-action follows soonest in those cases where there is 
a manifest fit of rigor. The last remark is perhaps applica- 
ble to most febrile diseases. In this form of the Scarlatina 
Maligna, as in the Scarlatina Anginosa, the danger is not to 
be apprehended from the first stage ; except that in it, short 
as it may be, more or less venous congestion of the internal 
parts exists, which may predispose to inflammation in the 
second, or excitive stage, in which there is an emergence 
of preternatural heat, and of arterial activity. It is, in- 
deed, in this second stage, that the main mischief is gene- 
rally produced, both in the above form of the Scarlatina 
Maligna, and in the Scarlatina Anginosa ; and these two 
varieties then differ in nothing but in the degree of their at- 
tendant excitement, which is greater in the first than in the 
last mentioned. Whatever putrid or malignant symptoms 
may appear towards the conclusion of each, they are sim- 
ply the products of the previous excitement ; and to consi- 
der them in any other light will give us most erroneous 
views of the nature and treatment of both these varieties. 
In the Scarlatina Anginosa, independently of the sore throat, 
and the occasional occurrence of pulmonary disorders, 
there are often early evidences of an affection of the brain! 
and of some of the abdominal organs. Among these evi- 
dences may be enumerated, constant pain, aching, giddiness, 
or some similar uneasiness in the head ; preternatural dis- 
tention and throbbing of the temporal and carotid arteries, 
with an increased heat of the forehead and whole hairy 



SCARLEt FEVER. 9 

scalp ; whilst the morbid appearances of the feces soon and 
clearly indicate the disordered state of the abdominal se- 
cretions, and consequently of some of the abdominal Visce- 
ra. themselves. If by any means, whether natural or arti- 
ficial, the excitement should be timely moderated, the mor- 
bid actions subside without deranging the structure of any 
vital part, and of course the patient is speedily restored to 
health. But if the excitement should not be moderated, it 
generally advances until it produces disorganization, and is 
then succeeded by a fatal collapse. In the Scarlatina An* 
ginosa, the excitement most frequently proceeds into the 
second, anxl sometimes even into the third week, before it 
occasions any mortal lesion. But in the more aggravated 
form of the Scarlatina Maligna, as the excitement runs much 
higher, so it terminates life much sooner, by disorganizing 
some vital texture. Yet diseases do not always observe 
the characters attributed to them in books, but change their 
forms at different periods of their course. Thus, as already 
intimated, the Scarlatina Anginosa sometimes assumes the 
appearance of the highly inflammatory form of the Scarla- 
tina Maligna ; and on the contrary, the violence of the Mat- 
ter may be so checked at its onset, as to cause it to put on 
the characters of the former. From a cautious survey of 
the symptoms during life, and from the examination of sev- 
eral bodies after death, I am warranted in affirming, that the 
brain, the liver, the stomach, the* intestines, and the lungs, 
are the parts most often inflamed ; and that the inflamma- 
tion in these parts is generally the cause of death, together 
with the affection of the throat. It is imprudent to disre- 
gard a particular symptom, which uniformly accompanies 
any febrile disease ; but, on the other hand, it is equally 
injudicious to fix the attention so exclusively upon that par- 
ticular symptom, as to withdraw it from many others. Sev- 
eral practical writers have certainly deceived themselves 
and their adherents, by considering the throat as the chief 
topical affection, and by disregarding those internal derange- 
ments, which are the constant concomitants of all the more 
urgent forms of the scarlet fever. It must not, however, 
be presumed from these remarks, that I mean in the least 
degree to depreciate an attention to the fauces. For, on 
the contrary, I think that they cannot be too narrowly 
watched, not only with a view to lessen the inflammation 



10 SCARLET FEVER. 

there, but to prevent it from spreading to the adjacent 
parts. It may be remarked, once for all, that whenever 
the respiration becomes at all oppressed in the scarlet fe- 
ver, the observation should instantly be directed to the pul- 
monary organs, and especially to the mucous membrane of 
the trachea, which is not unfrequently inflamed during the 
course of this disease. Having thus endeavoured to give a 
brief exhibition of the pathology of the inflammatory forms 
of the scarlet fever, I shall pass on to the consideration of 
the congestive varieties, which will enable me to advert 
more distinctly to what has been called the Scarlatina Ma- 
ligna. 

There are strictly two congestive forms of the Scarlatina 
Maligna, one in which the re-action is partially and irregu- 
larly developed, and the other in which it is almost entirely 
suppressed. The lines of distinction between these two 
forms being very obvious, it is only proper that they should 
be separately described. The first, therefore, shall be de- 
nominated the irregular, and the last the regular congestive 
form. 

The irregular congestive form is the least dangerous, and 
more protracted of the two ; yet it often proves fatal, either 
from some defect or delay in the treatment, or from the pe- 
culiarity of its nature. It comes on much after the manner 
of the preceding varieties ; but the first obscure stage, in 
which the sense of chilliness, head-ache, sickness, and lassi- 
tude commonly predominate, is almost always longer, and 
the following one of excitement much less perfectly display- 
ed. Indeed, in the second stage the heat is principally con- 
centrated about the trunk and upper portions of the thighs 
and arms, while some part of the wrists, hands, ankles, and 
feet, is often cool, or at least of the natural temperature. 
The excitement, too, varies in the course of the day. Du- 
ring each increase of fever the rash becomes more florid, 
and fainter as the re-action subsides ; both the heat and co- 
lour of the skin undergoing correspondent changes to these 
temporary exacerbations and remissions. The patient some- 
times complains of preternatural heat, and sometimes of 
preternatural coldness ; and occasionally of the latter, when 
the trunk feels hot to the touch of another person. The 
throat is always more or less red and swollen, after the oc- 
currence of the stage of imperfect excitement ; and specks! 



SCARLET FEVER. 11 

$r sloughs generally appear in a few days. In every modi- 
fication of the scarlet fever, with the exception of the regu- 
lar congestive, the state of the fauces is almost always pro- 
portionate to the degree of fever ; and as the excitement is 
less uniform and intense in the irregular congestive, than in 
the inflammatory forms, so the throat is in general less pow- 
erfully affected. Although the sloughs, commonly, be nei- 
ther so deep nor so extensive, as in the inflammatory forms 
of the scarlet fever, yet the throat is liable to put on a gan- 
grenous appearance, sometimes so early as the end of the 
first week, but far more frequently not until the second. 

It may be remarked, by the way, that, however striking 
may be the relation between the conditions of the throat 
and of the pyrexia in the scarlet fever, a similar relation 
does not so generally prevail between the conditions of the 
efflorescence and of the throat ; for there is sometimes a 
considerable affection of the latter, when the former is par- 
tial, and even evanescent. But to resume the description. 
In the irregular congestive form, the efflorescence is neither 
so much diffused, nor of so vivid a colour, as in the simple 
and inflammatory modifications ; and it is, besides, much 
more liable to disappear, and to leave a sickly pallidity of 
the face. Nor are the lips and edges of the tongue of so 
bright a red, as in the two last mentioned varieties. Soon 
after the attack, the mind often labours under dejection or 
alarm, which is strongly depicted on the conntenance ; but 
sometimes the patient is in a state of dulness, confusion, or 
indifference, and the eyes are then vacant, and the pupils 
dilated. Yet in some instances, the intellect remains clear 
for a time, though uneasiness is always felt in the head, and 
often a load or anxiety referred to the region of the heart. 
Delirium is not very common at the onset, but it very often 
appears afterwards and is generally a conspicuous symptom 
in the advanced stage. The stomach is flatulent ; the belly 
irregular ; the epigastric region frequently somewhat fuller 
than usual ; and the stools are always unnatural in colour 
and smell, indicating either a morbid or deficient secretion 
of bile. The pulse is low and oppressed in the first stage, 
and it rarely acquires much firmness or fulness in the sec- 
ond; though it is then quick and variable. In its natural 
progress, this form of the scarlet fever is often protracted 
to the end of the second week, and occasionally much long- 



12 SCARLET FEVER. 

er. When it ends successfully, the recovery is frequently 
very slow, on account of the great collapse which succeeds 
to the state of imperfect excitement. If it be not actively 
treated soon after the attack, there are, for the most part, 
symptoms which indicate some serious affection of the brain, 
liver, stomach, or of other important parts; and if these 
symptoms Should not be speedily arrested, they may gradu- 
ally or suddenly become much aggravated, and at last ter- 
minate life by coma, or low muttering delirium ; by vomit- 
ing and purging ; or by apparent- suiibcation. Towards 
the conclusion of such cases, there are frequently appearan- 
ces of a dissolved state of the blood, as inky petechias, ooz- 
ings of black gore from the nostrils and the like. 

The scarlet fever which appeared among the children in 
Heriot's Hospital in the autumn of 1804, was a degree of 
the irregular congestive form ; and would doubtless have 
proved very fatal, but for Dr. Hamilton's great attention, 
and judicious treatment. It appears from this author's con- 
cise but perspicuous history of the fever, that the symptoms 
were at first apparently mild. The throat was so little af- 
fected, that the uvula and amygdalae were only slightly 
swelled and inflamed ; and superficial suppuration and 
sloughing only existed in a few cases. The cutaneous ef- 
florescence was partial, mostly transitory, andieft the coun- 
tenance peculiarly pale ; the eye was dull and heavy, the 
thirst moderate, but the debility great. Sickness and pros- 
tration of appetite continued throughout the disease, and in 
some there were peculiar dejection and despondency hard- 
ly to be expected in such young subjects. The surface of 
the body was only occasionally of a pungent heat. The 
bowels were obstinately constipated, and the stools mostly 
black or greenish, and fetid, though sometimes less offensive, 
and of the colour and consistence of clay. The pulse was 
variable, never full, but always quick, except towards the 
end of the complaint, when it sometimes became slower 
than natural. The patients, Dr. Hamilton informs us, were 
the objects of his serious attention for twelve or fourteen 
days, and even six weeks elapsed before some of them left 
the sick-room. The danger in this epidemic obviously de- 
pended, not on the state of the throat, but of the internal 
parts, the congestions of which prevented the free emer- 
gence of the fever, and especially affected the functions of 



• SCARLET FEVER. 13 

the liver and intestines. That excellent author has report- 
ed the cases of three boys, who recovered from the fever, 
and who, in two or three weeks from their convalescence, 
were attacked with dropsy, to which they all rapidly fell 
victims.* Similar cases have come under my care ; and it 
has indeed always appeared to me, that fatal dropsies are 
far more liable to supervene the congestive, than the other 
varieties of this distemper. 

The irregular congestive differs from the inflammatory 
modifications of the scarlet fever, first, in generally having a 
more protracted stage of oppression ; and, secondly, in ha- 
ving a less perfect development of excitement afterwards. 
The danger in this form may be three-fold, — from the par- 
tial congestions about the large internal veins, from the un- 
equal distributions of blood to different viscera in the ca- 
pillary arteries, and lastly from the affection of the fauces. 
The congestions, however, of the first stage are not so con- 
siderable as to occasion any immediate mischief; though 
they pave the way to future lesions in the organs affected, 
and predispose them to be more readily influenced by the 
irregular distributions of blood, w r hich attend the stage of 
defective excitement. Hence we find, that visceral engorge- 
ments and gangrenes are more frequently the cause of death 
than the disorder of the throat ; at least repeated observa- 
tions and dissections have led me to this conclusion. In 
this form, the brain and liver are the organs which general- 
ly suffer most ; although, on examination after death, there 
are sometimes vestiges of low inflammation or of gangrene 
in other parts, especially about the stomach, intestines, fau- 
ces, and mucous membrane of the trachea. So much for 
the character and pathology of the irregular congestive form 
of this disease. 

The regular congestive form, next to be examined, so 
oppresses the vital functions in the first stage that there is 
then still greater internal remora of venous blood, and less 
internal and external re-action of the arteries than in the 
forementioned variety. The subjects of this modification 
are for the most part suddenly attacked. They become 

pale, faint, and sick ; and chiefly complain of pain, load, 

<<* 

* See Appendix III. p. 66, of Observations on the Utility and Ad- 
ministration of Purgative Medicines in Several Diseases. By James 
Hamilton, M. D. Fourth Edition. Edinburgh: 1811. 



14 SCARLET FEVER. 

or giddiness in the head ; extreme oppression ; and much 
uneasiness in the region of the heart, or at the pit of the 
stomach. Sometimes they at once sink, as if overcome by 
an uncommon shock,* and lie in a state of confusion and 
oppression, without making much complaint. At other 
times, they walk about pale and languid for two or three 
days, and then take to their beds, like persons completely 
worn out by some great fatigue, or mental anxiety. When 
the attack has once decidedly occurred, the respiration is 
either quick and anxious, or slow and impeded. There is 
often a mixture of livor and paleness in the face ; the eyes 
are frequently dull, but sometimes glairy, and they acquire 
a fatuous or an inebriated expression in the course of the 
disease. 

The mind, at first alarmed, confused, or dejected, soon 
becomes disordered with delirium ; or an indifference to 
surrounding objects, and a stupor, succeed, under which 
patients finally expire. From the beginning the pulse is 
generally low, impeded, and irregular, and commonly con- 
tinues so to the last ; but in those cases where there is a 
very slight degree of re-action, it sometimes has a short and 
rather a sharp feel for a certain period, and at last grows 
weak and undulating. At first the tongue is commonly 
whitish in the middle, paler than natural, and covered with 
a slimy saliva ; but towards the close it often becomes 
rough and darkish, and the breath is then usually offensive. 
The bowels are commonly distended with flatulency, con- 
stipated or irregular in the first stage, but frequently loose 
in the last. The feces are sometimes darker, at other times 
lighter than natural. The stomach is often extremely ir- 
ritable ; yet occasionally it retains every thing that is taken; 
though the deglutition becomes more difficult as the disease 
advances. This form of the scarlet fever frequently runs 
its fatal course in two, three, or four days, from the occur- 
rence of the extreme general oppression ; and there are 
almost always appearances of putridity in the last stage, 

* The lower orders of society, who generally speak in a highly fig* 
urative language, in describing the attack of such cases, have some- 
times told me, that the patient dropped down as if he had been shot 
through the head, or struck by lightning. This was clearly an exag- 
geration ; but at the same time it showed how deeply their imagina- 
tions had been impressed by the singular and striking mode of the at- 
tack. 



SCARLET FEVER. 15 

s#ch as oozings of blood from the mouth or nostrils, dark 
hemorrhages from the bladder or bowels, inky petechias, 
or gangrenous spots upon the skin. A few hours before 
death there is often a superficial glow of heat diffused over 
the body, accompanied with a darkly flushed face ; high 
breathing ; accelerated pulse ; and partial or general sweats. 
But this mere semblance of excitement soon subsides : the 
extremities grow cold ; the face assumes a cadaverous hue : 
and where the skin is pale it often has almost the smooth; 
waxen appearance of the surface of a corpse. 

In this regular congestive form, the efflorescence is from 
the first of a purplish or copperish hue, and deepens as the 
disease advances. Sometimes it quickly recedes without 
ever returning again ; a circumstance which, though not 
peculiar to the congestive modifications, is most liable to 
occur in them. In some very rapid and fatal cases of the 
form under consideration, the throat is but slightly affected ; 
yet in the instances which continue beyond the fourth day, 
there are generally specks or sloughs in some part of the 
fauces ; and I have witnessed those appearances when there 
had been previously little or no constitutional excitement. 
This fact seems to prove, that local inflammation may exist 
under the severest modifications of congestive disease ; 
and it also forms an exception to an assertion formerly 
made, that the affection of the throat is generally propor- 
tionate to the degree of constitutional excitement in the 
scarlet fever. But notwithstanding the above remark, re- 
lative to the throat, it is very doubtful whether the inflam- 
mation existing there, would of itself pass into gangrene, 
uninfluenced by the condition of the internal organs, and 
of the general system ; for the fauces usually do not assume 
an alarming appearance, until the disease is protracted to 
the fourth or fifth day, or until the vital energies evidently 
begin to fail. The af/ection of the throat, abstractedly con- 
sidered, is perhaps rarely the cause of death. In what 
parts then, it may be asked, are the principal derangements 
to be sought in this form of the scarlet fever ? It may truly 
be answered, in venous congestions of the brain, liver, 
spleen, lungs, or about the vessels of the heart ; for if these 
congestions be not timely removed, they produce an uni- 
versal collapse, and viscerial disorganizations, and also tend 
to change the constitution of the blood itself. In four mor- 



16 SCARLET FEVER. 

tal cases of this form, after death the brain and liver were 
found engorged with grumous blood, and the large vessels 
in the vicinity of the heart much distended ; with some 
loose and large coagula in the right cavities of that organ, 
while the left auricle and ventricle were empty and partly 
collapsed ; and it may be here remarked, that in most dis- 
eases of the strictly congestive character the right sides of 
the heart will be found much distended with blood after 
death. There was in one of the above cases an appear- 
ance of gangrene in the throat; but in the other three, 
which ended on the second day, the traces of disorder 
were comparatively slight in that situation. Dr. Currie, 
in alluding to this form of the Scarlatina, mentions that the 
heat does not rise much above the standard of health ; and 
on this ground seems to think, and rightly too, that the 
cold affusion is not applicable. In those cases which have 
fallen under my care, the heat has generally been rather 
somewhat below, than somewhat above the natural point \ 
and where the central parts have been warm or hot, the 
extremities have mostly been cold. It is deeply to be la- 
mented, that this enlightened physician did not more inde- 
pendently pursue the investigation of so obscure a variety 
of the scarlet fever ; for had he done so, there can be no 
doubt but he would have deviated from the beaten track of 
error. He acknowledges, with his accustomed candour, 
that all remedies had been equally unsuccessful in his hands; 
and this was not surprising, since the chief of those reme- 
dies were cinchona and wine, and since even he has so 
blended the symptoms of the first and last stages together, 
as to persuade himself, that this form is highly putrid from 
the very commencement.* Yet if accurately attended to 
from the first attack, it will be found, that the signs of pu* 
tridity or malignancy do not constitute a primary and es- 
sential part of this form, but are purely the consequences 
of excessive congestions ; for if we can remove the con- 
gestions in the beginning, we most certainly prevent the 
occurrence of putrid or malignant symptoms. It is only 
from a cautious and repeated survey of febrile diseases from 

* See Vol. II. p. 43, 44, of Medical Reports on the Effects of Wa- 
ter, Cold and Warm, as a remedy in Fever and Febrile Enseases. 
By James Currie, M.D. F.R.S. London : printed for T. Cadell and 
W. Davies. 1805. . 



SCARLET FEVER. 17 

their onset to their termination, that their real nature can 
be known ; and opinions principally deduced from the phe* 
nomena of the advanced stages, are as erroneous in theory, 
as they are dangerous in practice. The whole result of 
my experience in febrile diseases, has fully convinced me, 
that wherever there are appearances of malignancy in the 
last stages, these appearances have always been wrought by 
visceral inflammations, or visceral congestions, in the first 
stages. If this observation be more forcibly applicable to 
one febrile disease than another, it is to the highly inflam- 
matory, and to the highly congestive variety of the scarlet 
fever. 

In the open forms of fever, where heat and arterial re- 
action are universally developed, the danger is to be esti- 
mated by the degrees of the general excitement, and of the 
topical determinations ; whereas in the masked or conges- 
tive forms of fever, the danger is proportionate to the de- 
fect of the excitement, and to the extent of the local ac- 
cumulations of venous blood. Arterial excitement is an 
excess, venous congestion a deficiency, of natural action. 
The first is most liable to occur in constitutions of a high 
tone, the last in relaxed or torpid habits ; but there are ex- 
ceptions to this remark, since the applied cause may be so 
slight as to rouse a feeble frame into re-action, or it may 
be so severe as to oppress a vigorous one into perfect and 
overpowering congestion. The extremes of excitement 
and of congestion appear to be more common in tropical 
than in temperate climates ; and hence the great danger of 
the most concentrated attacks of the bilious remittent fe- 
ver, which are either highly inflammatory, or highly con- 
gestive. In Great Britain, we most frequently witness fe- 
vers of excitement, though those of congestion have not 
been sufficiently marked or investigated. The attention of 
the medical public has been too exclusively directed to the 
phenomena of the arterial system ; but it is to the venous 
system that we must look for the foundations of many im- 
portant diseases. From the whole tenor of these remarks, 
it will be readily perceived, that the irregular and the reg- 
ular congestive varietes of the Scarlatina Maligna may oc- 
casionally change their character ; since any cause which 
tends to lessen the venous fulness of the viscera may create 
the perfect re-action of the simple or of the inflammatory 
3* 



18 SCARLET FEVER. 

varieties. But as each of the modifications of this disease 
most commonly begins and proceeds in its peculiar char- 
acters, they all have been singly noticed ; and as the de- 
scriptions were drawn from an extensive observation at the 
bedside of the sick, it is hoped, that they will be found cor- 
rect in the most important particulars. 

Before concluding the history of the scarlet fever, there is 
one circumstance, to which I cannot refrain from pointed- 
ly adverting, and it is simply this : — when that disease pre- 
vails epidemically, children and even adults, some time 
after exposure, now and then die suddenly, from the ope- 
ration of the contagion, without any appearance of efflor- 
escence or of sore-throat. They are attacked with con- 
vulsions, or with the symptoms of apoplexy, and frequent- 
ly sink into insensibility and death in a few hours ; and 
therefore, properly speaking, such instances are but in- 
creased degrees of the regular congestive variety. No 
author, with whom I am acquainted, has noticed this the 
occasional effect of the contagion of the scarlet fever ; but 
as it took place casually during an epidemic, witnessed 
some years ago, I have deemed it a duty to record it here. 
Occurrences of this kind, it is well known, are not uncom- 
mon in the plague : and perhaps they happen oftener in 
the contagious fevers of this country than we are at pres- 
ent aware ; at least they are not limited to the contagion 
of this particular fever, but now and then follow that of the 
measles, and of typhus. It now remains for me to attempt 
their explanation. One of the first obvious operations of 
contagion, like that of cold, is a change of action in the 
cutaneous vessels, and a recoil of blood from the surface 
towards the centre. But contagion also produces, directly 
or indirectly, a peculiar effect on the nervous system, which 
is chiefly evinced in the disturbed functions of the brain 
and of the stomach. The change of action in the cutane- 
ous vessels, the recoil of blood towards the centre, the 
want of sensorial power, and the disorder of the stomach, 
all concur to oppress the heart and arteries ; and we ac- 
cordingly find, that the arterial circle every where beats 
more languidly than natural, a superabundance of blood 
being accumulated about the right side of the heart, and in 
the larger interval veins. Now this venous accumulation 
h sometimes so great as to overwhelm the functions of the 



SCARLET FEVER. 19 

brain, lungs, liver, or heart ; and the last mentioned organ 
collapsing, the usual interchanges of blood between the 
venous and arterial apparatus are carried on no longer, and 
the death of the whole system necessarily ensues. In gen- 
eral, however, the venous congestion is not thus mortally 
overpowering at once, but rather of such inferior degrees 
as to rouse at least into some resistance the latent energies 
of the heart ; and indeed it most frequently happens that a 
tone is at length acquired, which gradually extends through- 
out the whole arterial circle. The stage of re-action, 
therefore, whatever may be its final tendency, is immedi- 
ately beneficial. Whenever the stage of re-action is not 
partially or perfectly developed in febrile diseases, the dan- 
ger is instant and imminent. Most sudden deaths arise 
from great venous congestions. It cannot be doubted that 
venous congestions are cceteris paribus, more dangerous than 
arterial re-actions ; because, as the former are more rapid, 
and also more difficult to remove, so the latter relatively 
give longer time and greater facility for medical aid, nay, 
sometimes spontaneously subside into health. Arterial re- 
action is the mean by which nature preserves the human 
frame from the sudden and dangerous shocks of venous 
congestion, when it impedes or prevents re-action, he ought 
also to moderate arterial excitement, when excessive ; for 
as the congestion may be immediately, so the excitement 
may be ultimately fatal. But these points will be more 
properly illustrated in the treatment 3 and I shall now only 
further observe, that in three unfavourable cases, which 
followed an exposure to the scarlet fever, and which as- 
sumed an entirely apoplectic appearance, the brain and 
liver were found much, and the lungs moderately congested 
with venous blood. 

From all the preceding remarks it should appear, first, 
that the Scarlatina Simplex is generally an affection of 
slight excitement, which now and then, however, passes in- 
to the Scarlatina Anginosa : secondly, that the Scarlatina 
Anginosa and the first form of the Scarlatina Maligna are 
not only connected with sore throat, but with an excitement 
that may arise into sub-acute or acute inflammation : and 
thirdly, that the two congestive forms of the Scarlatina Ma- 
ligna are combined with less or more venous fulness, and 
the one with only a partial, and the other with an almost 



20 SCARLET FEVER. 

total want of excitement in the arteries. It is indeed to the 
different degrees of excitement and of congestion, thatall the 
modifications of the scarlet fever owe their pathological 
peculiarities, and that some of them are mild, others mod- 
erate, and the remainder severe. Hence it must be evi- 
dent, that the rules of treatment should be as various as the 
characters of this disease, and these rules shall now be con- 
cisely demonstrated. 

TREATMENT OF THE SCARLATINA SIMPLEX. 

The treatment of the most febrile complaints is founded 
upon the same or similar principles, in that notable stage of 
oppression, which invariably precedes the re-action or the 
hot stage which we strictly denominate fever. The first 
stage of oppression is a struggle between the innate powers 
of the body and the morbid cause : and therefore the prac- 
titioner ought to assist the efforts of nature in the first place, 
and to moderate them in the second, should they become 
greater than is necessary. If it be asked, what is meant by 
the efforts of nature, it may be rejoined, that their essence 
consists in the tendency which there is in the system to re- 
turn to the long established actions of health ; and we see 
this tendency conspicuously displayed in many diseases, 
though it may itself be ultimately productive of disorder, 
as already shown in speaking of the quality of re-action. 
Numerous writers on fever have re-echoed the opinion, that 
the excitement in the hot stage is in a ratio with the cold 
and rigor in the first stage, here termed that of oppression i 
but it would be far more correct to say, that the degree of 
re-action in the hot stage is in a ratio to the degree of inter- 
nal congestion in the first stage, except where that internal 
congestion is so extreme as wholly to overpower, or greatly 
to depress, the vis insita of the system. Yet as the signs 
of congestions in the stage of oppression are not uniformly 
the measure of the degree of the congestions themselves, 
it always becomes us to act with the greatest circumspec- 
tion on the first appearance of the precursory symptoms of 
fever ; and we should not, as is too generally done, leave 
them to proceed uninterruptedly, until all doubt of the ab- 
stract nature of the disease be removed, by the subsequent 
occurrences. It should be repeated again and again, that 
most of the rudiments of danger in fevers are laid in the first 



SCARLET FEVER. 21 

stage of oppression, and if we can alleviate the symptoms of 
that stage, we thereby usually insure a most favourable is- 
sue. This is beginning to attack diseases earlier than is gen- 
erally recommended ; but the force of remedies is then 
often far the greatest, since the morbid actions are but just 
engendered, and yield sooner than when they have acquir- 
ed a determined mode and character from continuance. 
For some years past it has been my study to attend closely 
to the first indistinct stage of febrile diseases ; and the sum 
of my observation is, that proper remedies applied at that 
period, at least, always render their course more moderate 
than it would otherwise have been. Hence whenever the 
scarlet fever has prevailed, I have directed parents to watch 
narrowly over their children, that they might inform me of 
the very first signs of the operation of the contagion : when 
called thus early, while paleness of the face and skin, head- 
ache, sickness, and lassitude, were perhaps the predomin- 
ant symptoms, I have found a brisk purgative first, an anti- 
monial emetic next, and the tepid bath last, of the most es- 
sential service : in fact, they free the system from the pres- 
sure of the plethora of the internal blood-vessels, equalize 
the whole circulation, and thus most frequently render 
the future case mild and manageable. Sometimes a com- 
bination of the tartrate of antimony with the sulphate of 
magnesia, or of the pulvis antimonialis with calomel, will 
rapidly reduce the heat and quickness of the pulse, by act- 
ing as an emetic and a purgative at the same time -> and the 
efficacy of one or other of the above compounds is exceed- 
ingly great in most incipient fevers of simple excitement, 
where the stomach has not been previously irritable. When 
the head or some other internal organ has appeared to suf- 
fer more than ordinary pressure in this stage of the simple 
Scarlatina, I have first put the patient into a warm bath, 
strongly impregnated with salt; and immediately afterwards 
have either applied a few leeches near the part most af- 
fected, or taken a very little blood from the arm. This 
practice, assisted by a brisk purgative, has, in general, 
not only given immediate relief, but powerfully contribu- 
ted to moderate the subsequent re-action. In the slight- 
er congestions of the first stage, the milder plan will gen- 
erally answer every purpose ; yet in cases where the symp- 
toms are suspicious, there need be no hesitation about 



92 , SCARLET FEVER. 

abstracting a little blood, the warm salt bath being premis- 
ed to stimulate the torpid surface. At this early period, 
and under these circumstances, large bleedings ought to be 
avoided, as they are often extremely prejudicial on the very 
first shock of the disorder. When the re-action is once 
fairly developed, we estimate by its degree, by the affection 
of the throat, and by the state of particular organs, and of 
the general system, whether the fever be strictly theJSear- 
latina Simplex ; and even if it should be found of that form, 
the sooner the excitement is restrained the better ; for if 
left alone, it might sometimes pass into the Scarlatina An- 
ginosa, and finally derange some vital part. In very young 
children the excitement of the simple scarlet fever is more 
especially to be checked ; as in them it sometimes directly 
affects the brain, or indirectly, through disordering the func- 
tions of the thoracic or abdominal viscera, and eventually 
leads to convulsions. 

For the above reasons, therefore, when the re-action 
emerges in the simple scarlet fever, the tepid affusions 
should be used four or five times in twenty-four hours, and 
an active aperient daily, with rest, ventilation, cleanliness, 
a bland liquid diet, and such measures will be all that are 
requisite. In the stage of collapse, which is usually very 
slight, milk, light animal broths, and similar articles, should 
always be preferred to wine and cordials ; because they re- 
store the strength much sooner, without the risk of crea- 
ting any secondary fever. Nor is this a matter of such 
small importance as it may at first sight appear ; forit must 
be remembered, that it is generally a disease of young sub- 
jects, who even after its decline are often easily excited in- 
to fever by strong stimulants. There are certainly exam- 
ples on record, where large quantities of wine have been 
given without apparent prejudice, if not with advantage, 
about the decline of the scarlet fever. Where the collapse 
is extreme, and unconnected with local lesions, such a treat- 
ment may sometimes be beneficially pursued. Yet in the 
greater part of febrile complaints, it is frequently quite un- 
necessary in the last stages, in which it may often occasion 
more mischief than advantage. Some cases of what has 
been termed hydrocephalus internus have followed the sim- 
ple scarlet fever in my practice, which seemed to result 
from the administration of wine in the last stage ; and I 



SCARLET FEVER. g| 

have seen tow inflammations of the chest and abdomen in- 
duced by the same cause, finally leading to dropsies of those 
regions. After recovery from the simplest forms of fever, 
the circulatory system is in a very susceptible state for some 
time ; and if there be anywhere a tendency, constitutional 
or acquired, to increased action, the administration of cor- 
dials is almost certain to produce an actual inflammation in 
that part. In strumous habits, this irritable state of the 
circulation is more particularly conspicuous, and in them 
enlargements of the internal and external glands are then 
readily induced by the free employment of wine. In short, 
the pernicious effects which so frequently result from this 
excitant, have long since made me abandon its exhibition 
altogether in children recovering from fever. Mild fresh 
ale has been my substitute, where any stimulus has been 
thought necessary for them : it excites much less than wine, 
and often tends to restore the tone of the general habit, 
and keep the bowels moderately open. 

After the cessation of the simple scarlet fever, the des- 
quamation of the cuticle will be much accelerated by the 
occasional use of the tepid bath, which is likewise a good 
preventive of those hydropic swellings, which may follow 
the mildest attack. But the best way to guard against such 
distressing consequences is to avoid stimulants, to keep the 
bowels daily open, to confine the patient within doors for 
several days after his complete recovery, and when he goes 
abroad to order him some additional clothing. These pre- 
cautions should be particularly enforced when the disease 
has been mild; as in such cases the relatives of children 
are generally thrown off their guard, never anticipating the 
chance of any secondary disorder. Several cases of drop- 
sy, which I have seen follow the scarlet fever, could be tra- 
ced to hasty and imprudent exposures to a cold or change- 
able atmosphere. The duration of the confinement with- 
in doors ought of course to be greatly regulated by the state 
of the weather, and may always be shorter in summer than 
at any other season of the year. 

The hair generally comes out on the abatement of every 
form of this disease ; and if the head be not shaved, it nei- 
ther looks nor grows well afterwards. But if the scalp be 
shaved two or three times, and repeatedly washed with 
warm water, when the patient is recovering, it will frequent- 



f 4 SCARLET FEVER. 

ly, I believe, grow and look as well as it did formerly. Nor 
ought the preservation of the hair to be deemed unworthy 
the attention of a medical man; for, independently of con- 
tributing much to the beauty of the form, it serves to pro- 
tect the integuments of the head from the influence of cold, 
and to lessen the force of accidents. When, however, the 
scalp is shaved, especially in cold weather, it should always 
be kept moderately warm afterwards, by flannel or some 
similar covering; since to the neglect of this precaution, I 
have sometimes traced severe head-aches, and occasional- 
ly even more serious affections of the brain. 

TREATMENT OF THE SCARLATINA ANGINOSA. 

As in the simple scarlet fever, the treatment of the first 
stage of the Scarlatina Anginosa should consist in brisk pur- 
gatives, a mild emetic, the warm bath, and bland, tepid dilu- 
ents ; unless there be decided marks of visceral oppression, 
and then, as an additional measure, a little blood should be 
drawn. As soon as the stage of excitement becomes appa- 
rent, by the whole surface being morbidly hot and dry, the 
cold affusions should be promptly employed, and repeated, 
for the first twenty-four hours, as often as the burning heat 
and dryness of the skin return. In several cases I have 
seen this disorder completely arrested, by five or six repe- 
titions of the cold affusion, used on the first day and night 
of the excitive stage. In the beginning of this modification 
it can hardly be said, with the exception of the throat, that 
any one part is positively inflamed ; though there are evi- 
dences of unequal distributions of blood in different quar- 
ters, and an elevation of arterial tone, which clearly indi- 
cate an approach to actual inflammation. It has repeated- 
ly struck me, that the great utility of the cold affusions con- 
sists, not so much in directly abating an existing topical in- 
flammation, as in removing or diminishing that general ex- 
citement of the heart and arteries by the continuance of 
which topical inflammation may be produced or prolonged. 
Hence their great efficacy at an early period of the second 
stage of those idiophatic fevers, in which the general ex- 
citements occasions or increases local irregularities in the 
circulation. 

According to my observations, however, it is only within 
the first three days of the stage of excitement, in this varie- 



SCARLET FEVER, 25 

iy of scarlatina, that the cold affusion will generally be of 
the most decided benefit; for though they may sometimes 
alleviate urgent symptoms when the re-action has continu- 
ed longer, they will rarely extinguish the pyrexia, as at an 
early period. When those febrile diseases which are called 
idiophatic have advanced beyond a certain term, they seem 
to have a sort of determinate duration ; at least our reme- 
dies have then less influence, so that they rather moderate 
than at once subdue the fever. If depended on singly, in 
the first, second, or third day of the stage of excitement, 
the cold affusions will not always succeed, as reiterated tri- 
als have enabled me to prove. On the whole, the advanta- 
ges of this valuable practice have been too highly estimated 
by Dr. Currie and some of his followers, in the scarlet fever. 
But in venturing upon this assertion, it is not meant to cast 
the slightest imputation on the memory of that excellent 
physician, whose labours deserve to be consecrated by a 
national monument. Yet such is the tendency of human 
nature to generalize too far, that when an useful discovery 
has been made in physic, its powers for the most part have 
been much overrated, especially by the person who first 
brought it decidedly into public notice and repute. This 
indeed might naturally be expected. The consciousness of 
having extensively benefited mankind tends to create an 
exalted enthusiasm, which overlooks many probabilities of 
failure, and anticipates little else than continued success. 

Having often been disappointed when I trusted to the 
cold affusions alone, it has for some time past been my es- 
tablished practice, to use them in conjunction with active 
purgatives, in the Scarlatina Anginosa. Experience has 
fully satisfied me, that these measures are far more effica- 
cious unitedly than separately applied, during the first, se- 
cond, and third day of the stage of excitement. After the 
last mentioned period, it will generally be much better to 
omit the cold, and to use the tepid affusions, which may be 
daily continued with the purgatives through the whole of 
the second stage. Some judicious practitioners of my ac- 
quaintance entirely confide in the tepid affusions and pur- 
gatives ; and the great success, which I have repeatedly 
witnessed from this treatment, warrants me in giving it a 
strong recommendation, in this variety of the scarlet fever. 

The late Dr. Clark, of Newcastle-upon-Tyne, was an 

4* 



26 SCARLET FEVER. 

advocate for the warm bath in the scarlet fever. It may b£ 
employed, whenever the tepid affusions are suitable, and 
possesses some great advantages over them in the conges- 
tive forms of this complaint, as will be shown in discussing 
their cure. The tepid affusions, to be efficient, should be 
used six or eight times every twenty-four hours, during the 
stage of excitement ; and the purgatives also should be then 
so administered as to produce four or five very copious mo- 
tions in the day. 

It is recommended, by high authorities, to exhibit cathar- 
tics during the day, that, the bowels being opened before 
bed-time, the patient may have a respite from their opera- 
tion throughout the night. Greatly as I respect some of 
those authorities, I cannot implicitly subscribe to this spe- 
cial recommendation. It is certainly highly advisable to 
get the bowels freely moved before bed-time: but why 
should the purgatives always be omitted in the night ? It 
is at that period, that the febrile exacerbation is commonly 
present, and therefore the practitioner should not allow it 
to proceed unimpeded : on the contrary, he ought to strive 
to lessen its intensity and duration, and this may often be 
most effectually done by using both the tepid affusions and 
purgatives freely during the night. When this treatment is 
pursued, it will be found, that the patient generally falls in- 
to a quiet sleep about the period of the morning remission ; 
whereas if it be omitted, he will usually pass an uneasy or 
a watchful night, and be restless the greater part of the next 
day. It is too common a practice to administer little or no 
medical aid during the night, in most idiophatic fevers. 
But in certain cases, the loss of so much time may be dan- 
gerous, if not fatal to the patient ; for if the excitement 
should run high at that time, and not be reduced, it may 
give rise to topical inflammations of the viscera, which no 
subsequent care can remove. 

It has already been hinted, that the affusions alone may 
fail in curing the Scarlatina Anginosa ; and this is some- 
times the case, though rarely in comparison, even when 
they are, cold or warm, jointly employed with active pur- 
gatives. In such untoward cases, morbid dissection will al- 
most invariably show, that inflammation of some of the vis- 
cera, as well as of the throat, was the cause of death. When, 
therefore, the cold or tepid affusions and purgatives do not 



SCARLET FEVER. 2? 

afford relief, the practitioner may be sure that there is some 
latent inflammation present, and should endeavour to de- 
tect and remove it, without loss of time. In several cases 
of this nature, minute investigation has satisfied me of the 
existence of visceral inflammation ; and moderate venesec* 
tion has been used with the most admirable effect. The 
crassamentum of the blood drawn was always covered with 
a buffy coat. When symptoms of a sub-acute visceral in- 
flammation appear on the second, third, or fourth day of 
the second stage, there need commonly be no hesitation 
about general blood-letting, provided it be used soon after 
those symptoms apparently originated. But when the vis- 
ceral inflammation has been permitted to advance for seve- 
ral days without resistance, or when it arises about the 
sixth or seventh day of the second stage, it often becomes a 
delicate point to determine whether the lancet should be 
employed. If there be appearances of universal collapse, 
and of an approach to gangrene in the throat, all thoughts 
of bleeding ought to be abandoned. But if, on the contra- 
ry, there be neither appearances of universal collapse, nor 
of approaching gangrene in the throat, general or local 
blood-letting may sometimes be safely and even advanta- 
geously used under the circumstances here considered. In 
such examples, the question is simply this — Whether is 
there greater danger to be apprehended from the inflamma- 
tion, or from the depletion ? Visceral inflammation has al- 
most invariably a natural tendency to terminate mortally. 
Depletion produces debility only, and debility alone is rare- 
ly the cause of death in fever. As there is, in this stage, 
more danger from the inflammation, than from the deple- 
tion, an attempt ought to be made to arrest the inflamma- 
tion, whencesoever it may proceed, or wheresoever it may 
be situated. When, by the long continuance of the inflam- 
mation, or the extreme delicacy of the patient, I have been 
deterred from general venesection, it has been usual with 
me to order several leeches near the region of the topical 
affections ; and considerable benefit has often resulted from 
this practice, especially when it has been followed up by 
purging and the warm bath. In such cases, blisters are 
sometimes beneficial, in conjunction with the means above 
mentioned ; but they should seldom be applied in the ad- 
vanced stage of the disease, as they then not only produce 



30 SCARLET FEVER, 

lost in convulsions ; and once saw an only child who died 
In that mode, while the nurse had fallen asleep. Impedi- 
ments to the respiratory functions are in general more 
speedily fatal to infants, than to those more advanced in 
life ; either from at once producing suffocation, or from 
sympathetically disturbing the brain, the last of which ef- 
fects is perhaps more frequent than the first. 

In the early part of my practice, I gave wine with much 
freedom in the advanced stages of almost every form of 
this disease ; but I gradually and most satisfactorily ascer- 
tained, that brisk and repeated purgatives in the first and 
second stages, and laxatives in the last, best removed the 
depression of strength, and rendered the use of wine far 
less necessary. Indeed wine should never be exhibited in 
the first and second stages ; and only in the third when 
there is an urgent debility. The diet should be of the 
lightest kind in the first and second stages, such as barley 
water with lemon juice, or milk whey. In the last stage, 
milk and water with a little arrow root, chicken broth, or 
beef tea, may generally be allowed. If any diffusible stim- 
ulants have been deemed requisite on the supervention of 
the stage of collapse, moderate quantities of mild fresh ale 
have often proved much more efficacious than wine, but 
particularly in children, who are so easily excited. In 
some instances, however, where the collapse was very 
great, I have given, at certain intervals, equal portions of 
Madeira wine and milk, with unequivocal benefit. But 
when wine is ordered, its effects should always be minutely 
observed, as was advised in typhus ; and whenever it aug- 
ments the fever, it should be abandoned for some less pow- 
erful excitant. In a state of convalescence, wine should 
hardly ever be allowed ; for it then tends to re-produce 
general excitement and topical accumulations, which may 
lead to fatal inflammations, or to dropsies of some of the 
visceral regions. 

In summing up the treatment of the Scarlatina Anginosa, 
it may be added, that if purgatives, aided by the cold or 
warm affusions, be properly exhibited from the beginning 
and during the advancement of the excitement, it will sel- 
dom be necessary to recur to bleeding in the second, or to 
wine in the last stage ; for the combined influence of these 
expedients, with an antiphlogistic regimen, most frequently 



SCARLET FEVER. 31 

so diminishes the general and the local excesses of the ar- 
terial sytem, as alike to ward off inflammation and debility. 
The publication of Dr. Hamilton's excellent work on purg- 
ative medicines has been doubly beneficial. In the first 
place, it removed many absurd fears & prejudices, andclear- 
ly showed the utility of purging in several diseases ; in the 
second place, it insensibly led us to push cathartics, with in- 
creased advantage, further than he had recommended, in 
the first stages of many highly acute distempers. Those 
physicians, whether practising in temperate or in tropical 
climates, who have tried large and repeated doses of calo- 
mel, must be fully convinced of their superiority in the on- 
set of ardent fevers ; but in no febrile disease do they seem 
of more decided benefit than in this, when daily determin- 
ed to the bowels by some other auxiliaries. Confident in 
this important fact by numerous observations, I have not 
hesitated to prescribe calomel boldly throughout the whole 
stage of excitement., always accelerating its operation by 
jalap or rhubarb, with moderate doses of the sulphate of 
magnesia ; and it is somewhat remarkable, that though I 
have given from six to eight grains of this mercurial to chil- 
dren, twice, thrice, or even four times in twenty-four hours, 
yet I have not once seen ptyalism supervene. It must how- 
ever, be observed, that I have never continued the use of 
the calomel beyond the decline of the stage of excitement 
in favorable cases, having always in them employed milder 
measures from that time. Decisive practice is only neces- 
sary during the urgency of the pyrexia, and it is the height 
of empiricism to continue it indiscriminately throughout all 
stages ; nay, such a procedure is almost always more dan- 
gerous than beneficial, and is calculated to bring the best 
remedies into disrepute. If we suppose, that the action of 
medicines is the same in disease as in health, we shall often 
be egregiously mistaken, and particularly in respect to cal- 
omel ; because a few grains of that preparation will usually 
affect the mouth in health, whereas in fevers attended with 
a hot and dry skin, we may give full and repeated doses 
without producing any such result. The operation of al- 
most all medicines is materially modified by the state of 
the system at the time of their exhibition ; so that small 
doses may at one period suffice to induce some desired end, 
and at another it can hardly be accomplished by large and 



m SCARLET FEVER. 

often renewed doses. It is still too much the fashion to de- 
claim against the bold administration of calomel in the com- 
mencement and progress of ardent fevers ; as if it were 
neither dangerous to trifle away those precious moments in 
palliatives, nor judicious to attempt a radical cure. Only 
let practitioners put calomel fairly and extensively to the 
test in febrile diseases, and we shall soon cease to have im- 
aginary and unfounded clamors against its free employment : 
for here it is a medicine which, like an injured and innocent 
individual, will have its character restored by an impartial 
and a strict examination. 

Nevertheless, calomel must not be entirely depended on 
in the Scarlatina Anginosa, since its efficacy will be greatest 
when it purges freely ; and such is often the torpor of the 
bowels, that it frequently fails to operate, unless assisted by 
the remedies before mentioned. The stools will always be 
found to indicate a disorder of the hepatic secretions ; and 
this is an additional reason why calomel should be boldly 
prescribed. The effect of purgatives on the heat of the 
skin is very conspicuous in this form of the disease : indeed 
I have never known them to fail in reducing it, and some- 
times several degrees, when they acted freely ; — an incon- 
testible proof that their influence is not confined to the pri- 
mae viae, but extends through the whole vascular system. — 
Yet highly as I commend purgatives in the first and in the 
second stage, they must generally be withheld when the stage 
of collapse approaches. Those milder medicines, strictly 
called laxatives, will then be the most beneficial ; except 
where the bowels have been previously neglected, and then 
one or two brisk purgatives may be given, the strength being 
sustained by cordials during their operation. Whenever 
the general system is in a state of actual or approaching col- 
lapse, cordials must always be combined with the evacu- 
ants ; for if the evacuants be employed alone, they will of- 
ten depress the vital powers irrecoverably. Many patients 
have, in fact, been lost purely from excessive purging in the 
last stage of acute fevers. The body is then prostrate from 
the previous excitement ; and we should make as little de- 
mands as possible upon its remaining resources. Our evac- 
uations, in particular, should be carried no further than to 
remove feces actually accumulated in the bowels, and to al- 
lay irritation. On tbe first attack of fevers, the strength 



SCARLET FEVER. 35 

may be said still to exist, though in a latent state ; and prop- 
er depletion, if we must preserve the chemical figure, will 
only serve to render it sensible again. But in the last stage^ 
the vital energy, like the vital heat, has begun to fail, and 
may be wholly extinguished by the very measures, which 
would have preserved it in the first stage. This difference 
between the beginning and the conclusion, is often remark- 
ably manifest in the Scarlatina Anginosa ; so much so in- 
deed, that what was excellent practice at the one time, 
would be mortal at the other. It is for want of having prop- 
erly marked the various stages, that so much discrepancy of 
opinion exists as to certain modes of depletion. If there 
are circumstances which make us turn from copious evacu- 
ations of all kinds, but especially from bleeding, still there 
are others which confessedly render this measure absolute- 
ly necessary ; so that when the symptoms cannot be early 
restrained by the ordinary evacuations, we must promptly 
have recourse to the lancet. Though it will appear, from 
the foregoing pages, that I have been cautious in advising 
venesection, yet in several instances I have bled moderate- 
ly and most successfully in the onset of the excitive stage of 
the Scarlatina Anginosa ; and can conscientiously declare 
that, at this period, and in this modification, I have not known 
it prejudicial in a single example. At the same time it is 
only proper to state, as a caution, that 1 have been called 
to cases where blood-letting was rapidly fatal, from having 
been employed at an advanced term ; and I have seen the 
same melancholy result from the application of the cold af- 
fusions, under similar circumstances. In the last stage, 
even the fatigue occasioned by the employment of the tepid 
affusions should generally be avoided; instead of which, 
partial ablutions should be used, and the fresh air freely ad- 
mitted into the chamber of the sick. The treatment, in 
short, must be materially regulated by the stages ; as will 
be more distinctly shown, in discussing the cure of the Scar- 
latina Maligna, to some forms of which venesection is more 
particularly adapted. 

TREATMENT OF THE SCARLATINA MALIGNA. 

When the scarlet fever is epidemical, any train of ill-de- 
fined signs of fever, accompanied with much disorder of the 
head and stomach, should always be most narrowly watched, 

5* 



34 SCARLET FEVER, - ' 

as they are often the precursors of the highly inflammatory 
or the highly congestive varieties ; and if they should not be 
relieved by purgatives, an emetic, and the tepid bath, a 
small portion of blood should be abstracted, for the reasons 
before stated. It was formerly noticed, that the most com- 
mon form of the Scarlatina Maligna only differed in the de- 
gree of its excitement from the Scarlatina Anginosa ; and 
indeed this seems implied in the writings of many authors, 
who assert, that the former does not so much differ in its 
very onset, as in its progress, from the latter. Yet it some- 
times happens, that we have the same terrific combination 
of symptoms at the close of the Scarlatina Anginosa, as at 
that of the highly inflammatory form of the Scarlatina Malig- 
na ; and the only difference then is, that the last mentioned 
has run a more impetuous course, producing the malignant 
symptoms in a less time. It is indeed the grand discrimina- 
tive sign of the highly inflammatory form of the Scarlatina 
Maligna, that the general excitement is brief and excessive, 
rapidly effecting the destruction of some vital organ. When, 
therefore, the excitive stage of this form is once fairly re- 
vealed, it is absolutely necessary to act with the greatest de- 
cision, since every moment of time is then most precious. 
If it should be allowed to proceed many hours without be- 
ing checked, it occasions the lesion of some important part, 
and an irretrievable exhaustion of the general powers. — 
Wine, bark, and aromatic cordials, so forcibly, so indiscrim- 
inately, and so fatally recommended by numerous authors, 
were once the means upon which, unfortunately, I relied 
for the cure of this modification of the scarlet fever ; and 
from repeated trials of them, I can truly affirm, that they are 
most pernicious in the first stage, and most destructive in 
the second. At the latter period they always add fresh mo- 
mentum to the impetuous excitement of the circulation, 
which, without such auxiliaries, has a tendency to consume 
the living energy, and to derange the organic tissue. In- 
stead, then, of adopting the stimulant plan, let the practi- 
tioner give a fair trial to the cold affusions as soon as the 
stage of excitement is developed ; and if they should not ef- 
fectually reduce the fever, let him not pause an instant long- 
er, but open a vein in the arm or neck, or a branch of the 
temporal artery, and allow the blood to flow until it is stop- 
ped by an approaching faintness. The rules laid down as 



X 



SCARLET FEVER. 35 

to phlebotomy in typhus, are also applicable here ; for in 
the acute inflammatory form of the scarlet fever, a repetition 
of the operation ought, if possible, to be avoided. But as 
the excitement is higher in this disease than in the inflam- 
matory typhus, the first blood-letting should be a most de- 
cisive one, so as to induce a lessened action in the whole of 
the circulatory system. If, however, it should not give a 
marked relief to the most prominent symptoms, a second, 
but more moderate venesection should be tried, in an hour 
or two afterwards, as that interval will generally afford suffi- 
cient time to estimate the effects of the first ; and even 
where a second bleeding may not be deemed adviseable, it 
will be mostly found advantageous to apply some leeches to 
the temples, or to the region of the liver. The head should 
always be much raised , and after having been shaved, it 
should be repeatedly covered with folds of linen soake \ in 
cold water. This practice in cases so violent is much su- 
perior to blistering the scalp. As half measures will 
only bring discredit upon the depletory treatment, the prac- 
titioner must not stop here ; but he should endeavour, im- 
mediately after the blood has been drawn, to get the bow- 
els freely and frequently moved, by very large doses of ca- 
lomel and jalap, aided by the sulphate of magnesia, or some 
other neutral salt. The purgative plan must be persisted 
in vigorously, in combination with the calomel, until 
there be a visible change for the better in every respect. 

But it must be recollected that these powerful proceed- 
ings should be solely confined to the stage of excitement, 
and that unless they are carried into effect within the first 
thirty hours of that stage, nothing decidedly beneficial is, 
for the most part, to be expected from them. Having too 
frequently witnessed the fatal results of depletion, when 
prosecuted in the last stage, and likewise the complete inef- 
ficiency of half measures in the second, I am certain, that 
nothing short of very early, prompt, and decisive blood-let- 
ting and purging can afford a fair chance of success, when 
the cold affusions fail in the first instance. No cases of this 
form of the scarlet fever have come under my observation, 
in which diffusible stimulants appeared to be really service- 
able in the first and second stages ; but on the contrary, se- 
veral cases have occurred in which they were rapidly de- 
structive. Bleeding and purging, however, employed at 



36 SCARLET FEVER. 

the time and in the mode above recommended, have been 
the means of snatching many patientsl&om the most immi- 
nent peril. Nevertheless, it is only justice to acknowledge, 
that though the depletory practice has frequently succeed- 
ed, it has also sometimes failed, even when fairly and fully 
tried. But what method of treatment is always successful 
in acute diseases ? The most judicious and well-timed de- 
pletion now and then fails in simple inflammation of the vis- 
cera : yet the knowledge of this fact forms no objection to 
its general applicability in those affections ; neither ought 
the occasional failure of the above measures, in the highly 
inflammatory variety of the scarlet fever, to be made a ground 
of objection against the general propriety of their early em- 
ployment. The more completely, however, to illustrate 
the evacuant treatment, a few cases shall be detailed, in 
some of which it miscarried, and in others succeeded. 

Some years ago, a robust girl, in the tenth year of her 
age, was attacked early in the day with chillines, head- 
ache, and sickness. She remained much oppressed during 
the whole day, and became restless and hot towards the 
evening ; when she complained much of stiffness of the 
neck, load at the stomach, and deep pulsating pain of the 
head. She passed a most uneasy night, and next morning 
the scarlet efflorescence was evident on the neck, breast, 
and arms ; the throat much inflamed ; the tongue white in 
the middle, and of a blood-red round the edges ; and the 
pulse quick, small, and hard. The temporal arteries throb- 
bed with violence ; and the surface was every where dry and 
pungently hot. At this period the cold affusions were thrice 
applied in the space of two hours, but they gave no perma- 
nent relief. Purgative medicines were therefore prescri- 
bed ; but as the greater part of them were rejected by the 
stomach, and as the symptoms continued to grow more 
urgent, eight ounces of blood were abstracted from a 
large orifice at the arm. This produced some alleviation 
for five or six hours, after which the fever returned with near- 
ly as much violence as before. The warm affusions were 
now used, in conjunction with aperients. But as the stom- 
ach again became irritable, the latter produced very little 
effect, and only a temporary reduction of the morbid tempe- 
rature was obtained by the former. The signs of excessive 
disorder in the stomach and head almost hourly augment- 



SCARLET FEVER. 37 

ed ; and on the fourth day the stage of co lapse supervened, 
attended with petechise, black tongue, dark bloody stools, 
fetid breath, and other malignant symptons. The patient 
died at an early hour of the fifth day. 

In this case, the cold affusions had, perhaps, a tolerably 
fair trial, at least it seemed useless to persevere longer in 
their employment ; but the stage of excitement had existed 
probably more than fourteen hours before their application 
— a great loss of time in cases so severe. The venesection 
should have been carried further in the first instance, or 
promptly repeated when the fever returned : and it is to the 
one or other of these omissions that the failure was perhaps 
chiefly attributable. At all events, it is not unlikely that 
a more copious detraction of blood might have so impeded 
the fever, and allayed the irritability of the stomach, that 
the purgatives administered would have operated freely, 
and thus given a chance of recovery. This reasoning is in 
some degree borne out by the morbid appearances which 
were exhibited on dissecting the body ; the brain, liver, and 
throat having presented the vestiges of considerable inflam- 
mation. 

A stout vigorous boy, about nine years old, went to school 
in the morning, apparently quite well ; but returned home 
in the afternoon, complaining of coldness, giddiness, and 
pain at his stomach. About eight o'clock in the evening he 
became hot and thirsty, and vomited some liquids which 
had been given him. Soon after this period, he said that 
he was drowsy, and at his own request was put to bed ; but, 
so far from sleeping, he had a most restless night, and early 
on the next morning was highly delirious. At this time a 
deep red efflorescence was diffused over the neck, breast, 
arms, and thighs. The temperature of his whole skin had 
been excessively high during the night. He continued to 
rave almost incessantly, and at nine o'clock on the follow- 
ing evening, twenty-nine hours from the period of his sick- 
ening, my opinion was first requested. The surgeon in at- 
tendance, from whom I obtained the preceding history of 
the case, informed me, that he had been consulted about 
fourteen hours after the attack ; that he had prescribed an 
emetic and a purgative, both of which had operated without 
producing the least relief; and that he had not been able to 
examine the throat, on account of the violence of the pa- 



38 SCA&LET FEVER. 

tient. At this time, the efflorescence chiefly occupied the 
neck, breast, and upper parts of the arms and thighs, and 
was of a deep red colour. Numerous small petechias were 
observable on different parts of the body ; the cheeks were 
deeply suffused and hot ; the lips livid and cool ; the tip of the 
nose and lobes of the ears quite cold, and the eyes bloodshot. 
The trunk was considerably above, while the extremities 
were somewhat below the natural temperature. The boy lay, 
with his eyes half open, in an apparent stupor for several 
minutes, then started upon his breech, threw his arms vio- 
lently about, and shrieked loudly. His breathing was quick 
and anxious : his pulse about 160 in the minute, and though 
very small, yet it firmly resisted pressure. Under such a 
combination of dangerous symptoms, little was to be ex- 
pected from any mode of treatment, at so advanced a peri- 
od of the second stage. The reduction of heat on some 
parts of the body, warned me, that the stage of collapse was 
not far distant ; yet the evidently engorged state of the 
brain, and the hard, resisting pulse, induced me to recom- 
mend venesection, as a dernier effort. Repeated attempts 
at opening the temporal artery having been frustrated, a 
large orifice was in consequence made in the median basilic 
vein. The blood flowed in a full stream ; but from the ex- 
cessive struggles of the patient we could not get more than 
six ounces. No benefit resulted from the operation, and 
his continued violence prevented us from having recourse to 
other expedients. General and strong convulsions came on 
about five o'clock on the subsequent morning, which rapid- 
ly put a period to his existence, about thirty-eight hours af- 
ter the first attack. 

From the speedy termination of this case, there was eve- 
ry reason to suppose, that the throat was not ulcerated. — 
After death, the abdomen became swollen and tense ; and 
part of the integuments of the back, abdomen, and thighs, 
remained of a deep, livid, red colour. An examination of 
the viscera was repeatedly requested in this case, but was 
always peremptorily refused. In all probability, the cause 
of death was an intense degree of cerebral inflammation, to- 
gether with a similar and co-existent affection of some of 
the abdominal organs. Venesection was certainly attended 
with no positive advantage, either because it was used at too 
advanced a period, or because a sufficient quantity of blood 



SCARLET FEVER. 39 

could not be obtained. Perhaps to a mind prejudiced by 
the doctrines of debility and putrescency, phlebotomy might 
appear contra-indicated, and even prejudicial in both of the 
examples above related. It is, in truth, no difficult matter 
to bring the evacuant practice into apparent discredit. De- 
pletion used too sparingly, or too late, will never be ser- 
viceable, and will sometimes really hasten the fatal event, 
by sinking the general powers, without removing the top- 
ical affections : — hence evidences might be easily furnish- 
ed, which would enable its decided opponents to draw in- 
ferences against its general utility. But as its failure, in 
cases like the forementioned, may generally be traced to its 
unseasonable, or to its partial application, so the following 
will serve to illustrate its efficacy, when opportunely and 
fully tried. 

An irritable boy, in the ninth year of his age, who had 
been infected from a mild case of the scarlet fever, began to 
complain after bed-time of faintness, pain and swimming in 
the head, and uneasiness of the stomach. He felt alter- 
nately chilly and hot, during the night, and next day the 
scarlet efflorescence began to appear, and the skin became 
of a high and uniform heat. At four o'clock in the after- 
noon, he had a manifest tendency to delirium, complained 
almost constantly of flying pains in different parts of the bo- 
dy, and was exceedingly restless. The pulse was above 140 
in the minute ; the tongue dry, and of a light red ; the throat 
inflamed; the neck stiff and painful; the eyes wild, suffu- 
sed, and sparkling ; the face swollen, and deeply flushed ; 
and the breathing hurried, almost to panting. In addition 
to these symptoms, there were fulness and tenderness in the 
epigastric region ; frequent retching or vomiting ; much 
flatulence of the stomach ; intolerance of light and noise : 
and a peculiar deep, throbbing pain in the forehead. When 
my advice was requested, the symptoms had existed about 
eighteen hours, including the stage of oppression ; but the 
excitement had not been developed more than half that pe- 
riod. Here then was a fair opportunity to prove the pow- 
ers of the depletory treatment, and it was accordingly adop- 
ted without loss of time. A large orifice was made at the 
arm, and the blood permitted to flow until it was stopped 
by an approaching syncope. About ten ounces were requi- 
site to produce this effect. When the patient recovered 



40 SCARLET FEVER, 

from the fainting, four leeches were applied to each temple ^ 
and soon afterwards half a scruple of calomel was exhibit- 
ed, and its action determined to the bowels by repeated 
doses of jalap and the sulphate of magnesia, and an occa- 
sional cathartic injection. The general and local blood- 
letting had effectually allayed the irritability of the stom- 
ach, and the aperient medicines operated powerfully in four 
or five hours* The most striking alleviation followed this 
practice ; and a regular perseverance in the use of calomel 
and other purgatives, brought the patient to a state of con- 
valescence in four or five days. In this case, the brain and 
stomach seemed the organs chiefly disordered ; and I have 
not the smallest doubt but it would have ended unsuccess- 
fully, if depletion had not been promptly and decidedly pur- 
sued. 

About the same period, a girl in the thirteenth year of 
her age, came under my care, who, nearly twelve hours af- 
ter the developement of the excitement, was afflicted with 
a violent, continued pain in the head, and vertigo; confu- 
sion of mind ; sense of faintness ; load at the stomach ; nau- 
sea and retching ; great general restlessness ; and quick, 
anxious breathing. The skin was excessively hot, and of 
a deep scarlet colour, and there were considerable redness 
and swelling in the fauces. The eyes were morbidly sen- 
sible to light; there was an inexpressible anxiety depicted 
on the countenance : and the temporal arteries throbbed 
forcibly, and the pulse at the wrist felt like a small chord. 
Twelve ounces of blood were abstracted from a branch of 
the temporal artery, which brought on complete syncope ; 
when that, however, receded, the patient expressed herself 
much relieved. But as there still remained evidences of a 
preternatural accumulation of blood in the head, purgatives 
were freely exhibited as before, and cold stupes frequently 
applied over the scalp. When the medicines had acted 
plentifully, there was a still further abatement of the urgent 
symptoms ; and they were therefore omitted for a time, the 
room where the patient lay being kept very cool and quiet. 
But after the lapse of three or four hours, there was an ev- 
ident exacerbation of the fever. As the mischief seemed to 
be still seated in the head, the hairy scalp was shaved, and 
ten leeches applied to the temples and forehead. The pur- 
gatives were again administered with great freedom, until 



SCARLET FEVER. 41 

they produced several copious evacuations. These mea- 
sures had the desired effect; for they not only completely 
broke the force of the fever, but removed the affection of 
the head, and the recovery of course was rapid. Yet the 
patient was for some months afterwards troubled with a 
deafness, which had appeared at an early stage of thq dis- 
ease. The brain was perhaps the only viscus attacked with 
inflammation, which at first was merely checked, but event- 
ally subdued by the blood-letting and by the brisk purga- 
tives. 

Several other cases of the acute inflammatory form of the 
scarlet fever have been treated successfully under my im- 
mediate inspection, by early and active depletion ; but the 
similarity of their symptoms and results to those already 
reported, renders an account of them unnecessary in this 
place. Possibly it may be contended by the abettors of the 
doctrines of debility, that in the two cases last detailed, 
there were few or no marks of malignity present. If any 
practitioner were so infatuated as to wait for the accession 
of the putrid symptoms, to satisfy himself of the malignant 
nature of the disease, he would unquestionably lose every 
patient who laboured under this form of the scarlet fever* 
The putrid symptoms only occur in the stage of collapse, 
and are the products of the preceding stage of excitement. 
An attentive study of the disease at the bed-side, from its 
commencement to its termination, will convince any candid 
mind of the truth of these assertions. But if there should 
be any one so sceptical as not to be satisfied by a contem- 
plation, of the symptoms during life, let him in mortal cases 
examine the viscera of the head, chest, and belly, and all 
his doubts and prejudices will be entirely removed. 

In some instances of this form, I have bled twice freely in 
children from the arm, from the external jugular vein, or 
from the temporal artery, before a sufficient impression 
could be made upon the visceral inflammation; yet as it 
has always been my aim to make one general bleeding an- 
swer if possible, I have never had recourse to a second, but 
from the most imperious necessity. It has appeared to me 
a great error to trust solely to venesection, in fevers con- 
nected with very high excitement. For, to give efficiency 
to such a practice, the evacuations of the vital fluid must 
generally be repeated again and again, and even after all 

6* 



42 SCARLET FEVER, 

they often fail to arrest the progress of the local affections : 
and where they do apparently arrest those affections, J;hey 
not unfrequently induce an irritation and exhaustion, under 
which patients may rapidly sink, or from which at least 
they recover slowly, and seldom afterwards gain their pris- 
tine vigour. It would be a most instructive lesson to the 
medical world, if those practitioners w r ho have trusted to 
profuse bleedings alone were candidly to state the whole 
results of their experience ; and I cannot but apprehend 
from my own observation, that their successful cases would 
be arranged with many melancholy instances of failure. 
The partial statement of facts, with regard to a particular 
practice, is frequently both deceptive and dangerous ; since 
it may lead us to place so complete a reliance upon it, that 
we only might be convinced of its imperfections by its actu- 
al miscarriage on our fellow-creatures. Perhaps the histo- 
ry of medicine, from Hippocrates to the present time, would 
bear me out in the assertion, that physicians in all ages have 
been too much in the habit of trusting to a favourite, unas- 
sisted remedy ; and this has been more especially the case 
with respect to venesection, upon which so many eminent 
men have exclusively rested their hopes of success in in- 
flammatory diseases. If bleeding and purging had always 
been combined in the treatment of highly acute complaints, 
the results would have been much more favourable, than 
where either of those plans had been separately pursued. 
It is in the early, decisive, yet moderate use of the lancet, 
speedily followed up by purgatives and alteratives, that we 
shall alike avoid rashness and timidity ; and it is in a judi- 
cious combination of these three agents, that a method will 
be formed far superior to any plan founded on an exclusive 
preference for one remedy. If it be injudicious and dan- 
gerous to bleed too often and too largely in adults, it is still 
more so in children, many of whom have been lost from a 
disregard of the golden medium as to venesection. Were 
it inquired why large bleedings are more dangerous to chil- 
dren than to adults, I should answer, that in the former, 
they induce greater nervous irritation, and greater consti- 
tutional debility ; and these effects may be marked by a 
short, weak, hurried, anxious respiration, and by a pulse 
which has a sort of tremulous and convulsive rapidity. 
Large losses of blood in children bring on an excessive re- 



SCARLET FEVER. 43 

action of the heart and arteries, different from that which 
existed before the operation. It is a re-action combined 
with an irritability of the nervous system, and with the agi- 
tated struggles of wasted strength ; and therefore it can on- 
ly be allayed by soothing means, such as opiates, perfect 
quietness, free ventilation, or the tepid bath. 

But if such are the perils of excess, we have nothing to 
dread from seasonable and moderate vensesection in chil- 
dren, when they labour under fevers combined with inflam- 
mation : and in that variety of the scarlet fever under con- 
sideration, it will be found indispensable in a large majority 
of cases ; since the cold affusions, however promptly appli- 
ed, will often not make the slightest impression, and since 
the operation of purgatives alone would be much too slow 
to arrest its rapid advancement. But after early and mod- 
erate bleeding, we must not pause an instant, as before 
hinted, but prescribe active and alterative purgatives with 
a boldness commensurate to the danger ; for upon their ef- 
ficacy the favourable issue of the case will ultimately de- 
pend, whatever immediate benefit may have been derived 
from the blood-letting. In speaking of the Scarlatina An- 
ginosa, I have strongly insisted on the efficacy of full doses 
of calomel, succeeded by other purgatives, in the stage of 
excitement ; and in this more impetuous form, the calomel 
must be still more freely administered, and the same or 
even greater care must be taken speedily to assist its ope- 
ration by the bowels. To use unnecessary delay in such 
cases, in the exhibition of cathartics, is to risk the life of 
the patient ; and as the morbid actions are unusually ac- 
tive, so must be the nature of our remedies. When we re- 
collect the great length of the intestines, we cannot be sur- 
prised that frequent and copious motions should lessen the 
general excitement and the topical determinations; and, 
doing this without the hazard of consequent debility, they 
are particularly adapted to the second stage of inflammato- 
ry fevers, after the judicious employment of the lancet. 
But in almost every such fever the abdominal secretions will 
be found disordered, at least they are strikingly so in the 
variety under consideration ; and calomel not only tends to 
restore them to a natural state as a purgative, but likewise 
exerts an influence over all the capillary system, by which 
it equalizes the circulation. That portion of blood which 



44 SCARLET FEVER. 

was oppressively superabundant in one or more parts, cal* 
omel diffuses throughout the whole habit ; but there are cer- 
tain circumstances which must be overcome, before it can 
generally effect so beneficial a change. Whenever there 
is an excessive emergence of heat and of arterial re- action, 
especially when combined with a cerebral determination of 
blood, the body resists both the purgative and the specific 
action of calomel ; and under such a morbid condition, cal- 
omel will seldom bp useful, except in conjunction with oth- 
er depletory measures. But where bleeding has been pre- 
mised, or where evacuations of the bowels are simultaneous- 
ly procured, the universal excitement and its concomitant 
oppression are so redueed, as to render the system permea- 
ble to the power of calomel ; and acting then under the 
most favourable circumstances, it produces benefits which 
cannot be wrought by any other medicine, and. like oil 
poured over ruffled water, it reduces agitation into calmness. 
We have often erred in our opinions of calomel, from con- 
sidering its operation the same in ardent fevers as in affec- 
tions unattended with increased heat. But its effects are 
varied by the condition of the body under which it is given ; 
and where it has to encounter a highly febrile action, the 
system receives no shock from its free administration, as its 
main force is spent on the reduction of that morbid action 
alone. Yet when that morbid action is subdued, the sys- 
tem returns towards the ordinary laws of health, and the 
calomel must be withdrawn ; because its further use would 
then produce different and perhaps prejudicial consequen- 
ces, seeing that the present state of the system is widely dif- 
ferent from the past. 

During the administration of the purgatives, the tepid 
affusions will sometimes be found useful ; but where the 
abdominal viscera seem to have been considerably affected, 
the warm bath should have the preference. Both these 
expedients, when properly employed, tend to lessen nerv- 
ous irritation, and arterial excitement, but more especially 
after bleeding, and while an action is maintained on the 
bowels : sometimes they equalize the circulation, like calo- 
mel, by creating an universal perspiration, which considera- 
bly diminishes the internal affections. Still, however, they 
must only be considered as second means at the best, in this 
violent variety of the scarlet fever ; and therefore the prac- 



SCARLET FEYER. 45 

titioner should never allow his attention to be occupied by 
them exclusively, since far more effectual measures are at 
the same time necessary. It is one of the nicest points in 
the practice of physic, not to be too profuse or too sparing 
in our applications, but to make their united force exactly 
equivalent to the reduction of the prominent symptoms. 
To prescribe mild measures for dangerous, or active ones 
for slight affections, equally betrays a want of discernment ; 
but errors of the first kind are generally soon fatal, whereas 
those of the second may be repaired by the renovating 
powers implanted in the system. Whatever energetic 
means may be required in the stage of excitement for this 
form of the Scarlatina, it must never be forgotten, that 
those means are only to be continued during that stage, and 
while the dangerous symptoms remain unsubdued ; since to 
continue powerful evacuations when the symptoms for which 
they were at first prescribed have actually been removed, 
or to push them on vigorously when universal collapse ap- 
proaches, would be an indiscriminate rashness in the prac- 
titioner, that might be hazardous, if not mortal to his pa- 
tient. In this form, the excitement varies in its duration 
considerably in different subjects : sometimes it terminates 
in less than twenty-four hours, as in a case already report- 
ed 5 and in other instances it is protracted to the third, fourth, 
or fifth day, but seldom longer than the last mentioned term. 
For these reasons, there is a considerable range as to the 
time in which depletion may be employed 5 but it may al- 
ways be made with more boldness the nearer it is used to 
the onset of the stage of excitement. If the evacuations 
should arrest, generally and locally the morbid activity of 
the circulation, the strength of the patient will thereby be 
saved ; because the continuance of that morbid activity 
would exhaust much more than the evacuations, and be- 
sides it has a tendency to derange the structure of vital 
parts. It is not an uncommon thing to hear some practi- 
tioners contend, that the strength of a febrile patient should 
be nursed and preserved in the beginning, to enable him to 
meet the collapse which must necessarily occur at the 
close : and under this fallacious, this perilous impression, I 
have seen cordials administered with a view to guard against 
the very consequences which they were powerfully calcu- 
lated to produce. The collapse in the last stage of fevers 



46 SCARLET FEVER. 

attended with an open and universal developement of heat, 
is proportionate to the degree of arterial excitement which 
always precedes the collapse ; and whatever tends to in- 
crease the excitement also tends to increase the collapse ; 
and on the contrary, whatever lessens the excitement like- 
wise lessens the degree of collapse. We cannot therefore 
support the strength of patients by cordials during the ex- 
citement, since they necessarily augment the excitement 
which ultimately occasions the collapse ; but we most effec- 
tually support their strength by promptly checking the ex- 
citement at its first invasion, or before it has advanced far, 
through the agency of measures which remove heat, allay 
irritation, and lessen the force and the quantity of the cir- 
culating fluids. We now hear much less of malignant and 
putrid fevers than we did formerly, and what is the princi- 
pal cause of this ? What but the active and antiphlogistic 
treatment more generally used at the commencement of 
such affections, — a treatment which destroys or moderates 
the excitement in embryo, and thus prevents the appear- 
ance of malignant symptoms, the mere products of unre- 
strained inflammations or congestions. Upon this point I 
must be allowed to speak decidedly, because I was once so 
far misled by great authorities, as to exhibit stimulants even 
in the beginning of some idiopathic fevers ; and I now en- 
ter my earnest protest against their too early exhibition, 
that others may hereafter avoid the mistakes which arise 
from a deference to the recorded opinions of our predeces- 
sors. It is still too much the custom, among certain prac- 
titions, to have recourse to diffusible stimuli, the moment 
they apprehend that any typhoid signs have appeared ; and 
even in the most approved of our treatises on the scarlet 
fever, we find the stimulant practice fully and unequivo- 
cally recommended in what has been termed the malignant 
variety. 

When the excitement has been timely checked in the 
highly inflammatory form of the Scarlatina, the stage of 
collapse will be comparatively slight ; and a milk diet, with 
quietness, proper ventilation, and laxatives, will be all that 
are necessary to ensure recovery. During convalescence, 
great care must be taken to avoid cold, and whatever may 
excite the vascular system ; as very slight causes may re- 
produce visceral inflammations, or occasion dropsical effu- 



SCARLET FEVER. 47 

sions — for the prevention of both of which effects, purga- 
tives and the tepid bath are amongst the best measures. 
If the excitement should not have been successfully restrain- 
ed, the stage of collapse will almost always be combined 
with disorganization ; and therefore little good is in general 
to be expected from medical means. But as the disorder 
of function sometimes assumes the character of derange- 
ment of structure, we should never abandon any case as 
utterly hopeless ; on the contrary, we should be the more 
attentive in our endeavours to save the patient, so that if 
we fail, we may be satisfied of having performed our duty. 
Venesection is then entirely out of the question, and the 
only evacuation that can be safely induced must be by ape- 
rient medicines; and even that must not be pursued too 
far, lest it sinks the feeble remains of life. The strength 
should be supported under the operation of the laxatives 
by small and repeated draughts of warm wine; and if any 
irritation should arise, it may be allayed by moderate doses 
of opium, which are occasionally more beneficial than might 
be expected, especially when combined with the aromatic 
confection and camphor. The hands, face, breast, and 
soles of the feet, may be now and then washed with warm 
brandy and vinegar, and some refreshing aromatic water 
may be sprinkled over the bed-clothes. Ventilation and 
cleanliness should be particularly regarded, since they are 
necessary in all the forms, and at all the stages of this and 
every other contagious fever. Frequent observations have 
convinced me, that the accumulation of any febrile conta- 
gion is highly detrimental to the sick : it having the power 
to augment the fever in the first stages, and to change the 
constitution of the fluids in the last. 

In the irregular form of the congestive scarlet fever, or 
that in which the excitement is partially developed, purga- 
tives and the warm bath are the best remedies. But to 
ensure success, they must be employed from an early peri- 
od, and diligently persevered in for some time afterwards. 
The bath should be used about twice every twenty-four 
hours for the first four or five days, and then only once in 
the same term, until there be appearances of recovery. 
The purgatives should be so exhibited as to move the bow- 
els about four or five times daily, so long as the general op- 
pression and irregular state of the excitement remain. As 



4-8 SCARLET FEVER. 

soon as the pulse is free and full, the skin of a moderate 
and equable heat, the general oppression overcome, and the 
hepatic disorder corrected, the purgatives must be admin- 
istered more sparingly ; nor is it ever prudent to omit them 
entirely, until a state of complete convalescence be estab- 
lished, because there is a great tendency to relapse in this 
modification of the disease, particularly if the bowels be 
neglected after a remission has occurred. 

v The belly is generally torpid at the beginning, and the 
dark or clayey appearance of the excrement shows, that 
the functions of the liver are much affected; indeed, if 
they can be brought to a natural state, recovery will mostly 
follow apace. On this account calomel is peculiarly ser- 
viceable, which should be given with considerable freedom 
at first, and its action on the bowels accelerated by the 
compound powder of jalap, or the tartarized infusion of 
senna ; the last of which, when rightly prepared, is a med- 
icine which children like better than almost any liquid pur- 
gative. When the feces have become of a healthy colour, 
and the functions of the skin have been restored, the calo- 
mel may be omitted, and a little castor oil occasionally sub- 
stituted, or calcined magnesia mixed with lemon juice. In 
conjunction with aperients and the warm bath, small doses 
of pulvis antimonialis or of the liquor ammonfe acetatis 
may be sometimes useful as diaphoretics ; although small 
and repeated doses of the carbonate of ammonia are often 
superior in occasioning a gentle and general perspiration, 
which materially contributes to remove internal congestion. 
It is commonly necessary, in this form of the disease, to 
give moderate portions of some diffusible stimuli as soon as 
the stage of collapse approaches ; and mild brisk ale, or 
porter, is one of the best that can be given to children, or 
a little Madeira wine diluted with milk. 

In bad cases where, from neglect, the feces have been al- 
lowed to accumulate, it is sometimes absolutely necessary 
to purge briskly for a short time, even in the stage of col- 
lapse. And whenever this is done, the strength of the pa- 
tient must be supported by the occasional exhibition of 
good wine, during and after the operation of the purgative* 
as has been fully explained in treating of typhus. But it 
must be recollected, that so long as the stage of irregular 
excitement continues, wine is generally a dangerous agent : 



SCARLET FEVER. 49 

warm diluents, such as gruel or weak chicken broth, being 
infinitely preferable. Great errors have been sometimes 
committed in the use of the cold affusions, from not having 
rightly discriminated the congestive from the other modifi- 
cations of the scarlet fever. In two instances of the irreg- 
ular form now under review, I have known the application 
of cold water to the surface speedily sink the patients into 
an irretrievable collapse, and in some others have witnes- 
sed most distressing effects from the same practice. It may- 
be laid down as a practical maxim, that in this form of the 
disease the cold affusions are decidedly prejudicial. It 
was formerly noticed, that the scarlet fever, which occur- 
red among the children in Heriot's Hospital, was allied to 
the irregular congestive variety ; and Dr. Hamilton suc- 
cessfully encountered it by repeated purging — a mode of 
treatment which, with the assistance of the calomel and 
the tepid bath, will be found perhaps the best in every sim- 
ilar modification of the disease. In three or four cases, I 
ventured upon early and moderate venesection, and it seem- 
ed to shorten their duration. But my experience does not 
warrant me to speak decidedly of its pow r ers, in this varie- 
ty of the distemper, having generally trusted to the meas- 
ures already recommended. For sometime after conval- 
escence from the irregular form of the congestive scarlet 
fever, great care is requisite ; as there is not only a singu- 
lar tendency to obscure visceral inflammations, but also to 
dropsies. The occurrence, however, of both these affec- 
tions may frequently be prevented, by the occasional use of 
laxatives and the tepid bath, together with warm clothing, 
a milk diet, and a residence within doors for two or three 
weeks. The dropsies of the chest and abdomen, which 
supervene after recovery, are commonly the effect of a low 
inflammation of the pleura, or of the peritonaeum, or of 
some obstruction left in the liver ; and therefore those 
parts should claim particular attention for some time after 
the abatement of the original fever. As the regular con- 
gestive is an aggravation of this modification, and as it con- 
stitutes one of the chief varieties accounted malignant, I 
shall enter more into detail respecting its treatment. 

The regular form of the congestive scarlet fever, the cure 
of which is next to be explained, is occasionally preceded 
for two or three days by obscure febrile symptoms, as chil- 

~7* 



60 SCARLET FEVER. 

liness, paleness of the face, heaviness of the head, languor f 
and loss of appetite. If the attack were reckoned from the 
time that the above mentioned symptoms occurred, we 
could say with truth, that the lancet might he used with 
propriety so late as the second or third day. But as this 
form generally makes an open, sudden, and overpowering 
invasion, the period proper for venesection is for the most 
part limited within the first twenty-four hours of the decid- 
ed signs of congestion. After the appearances of great and 
general oppression occur, the stage of universal collapse 
soon supervenes, and the mass of blood is changed into a 
dark, uncoagulable gore. As soon therefore as the attack 
is clearly manifested, not a moment should be lost in having 
recourse to the most active measures ; as delay is more 
dangerous in this than any other modification of the disease. 
The first thing that should be done in these cases is to 
immerse the patient in a warm bath strongly impregnated 
with salt, provided it can be speedily prepared ; and while 
he remains in it, or immediately after he comes out of it, 
as much blood should be abstracted as will free the pulse 
from oppression ; the skin in the mean time being well rub- 
bed with coarse flannels dipped in some stimulating liquid, 
such as warm vinegar and salt. The warm bath and fric- 
tions cause a flow of blood towards the surface, and thus 
contribute to relieve the central parts from congestion ; and, 
in fact, unless these be premised, it is generally a very dif- 
ficult matter to abstract blood in the most severe instances, 
so striking is the change induced in the cutaneous circula- 
tion. Where the warm bath cannot be readily obtained, 
frictions by warm flannels and warm stimulating liquids 
must be used instead, and bottles or bladders of warm wa- 
ter applied to the feet and other parts ; that is to say, this 
plan must be pursued previously to blood-letting, where 
the internal congestions afford sufficient time, and where 
the skin is of an irregular heat, for want of its ordinary dis- 
tributions of the sanguiferous fluid. The writings of Hip- 
pocrates and of Celsus show, that the ancients paid far 
more attention than the moderns to the use of the warm 
bath and frictions of the skin in febrile diseases ; and in the 
congestive modifications, they are certainly expedients well 
fitted towards equalizing the circulation. Among the mo- 
derns, however, the ingenious and elaborate Dr. Willan 



SCARLET FEVER. 51 

speaks favourably of warm brandy and vinegar as an appli- 
cation to the skin, in what he denominates the malignant 
Scarlatina ; though his general remarks on the subject are 
strongly imbued with the doctrines of malignity. Blood 
must be drawn with much more caution in the highly con- 
gestive than in the highly inflammatory form ; since the 
state of the circulation in the one differs essentially from 
that in the other. In the highly inflammatory form, we 
have a rapid tense pulse, with all the signs of an excess in 
the force and in the frequency of the whole arterial streams 
of blood ; and therefore, when called early, we may safely 
venture on decisive venesection, the effects of which will 
then only be to reduce the preternatural fulness and rapidi- 
ty of the arterial currents to something like the ordinary 
calmness of health. But in the highly congestive form of 
the scarlet fever, there is an actual diminution in the force 
of the arterial circulation, on account of an excessive accu- 
mulation of blood in the venous apparatus of the interior 
parts ; and therefore, if we bleed too largely, we may so 
diminish the already oppressed energies of the arterial sys- 
tem, as to make the heart at once sink under the shock. 
Consequently, small or moderate bleedings are generally 
preferable in this congestive modification ; although instan- 
ces now and then occur in which full bleedings are requir- 
ed, to restore the lost equilibrium. At first sight, it might 
appear almost ridiculous to say, that phlebotomy is a direct 
stimulus ; but it really is so when properly employed, in 
the congestive examples of fever. It frees the over-bur- 
thened vessels from a portion of the oppressing cause, and 
thus brings those innate powers into play, by which the ba- 
lance is maintained between the two systems of veins and 
arteries. In highly congestive cases, life is oppressed and 
endangered by an almost stagnant plenitude of blood, some 
of which must be taken away, before the common course 
and purpose of the remainder can be restored ; as the light 
of a candle may be nearly extinguished by too great an ac- 
cumulation of melted wax round the wick, and yet be quick- 
ly revived by drawing off the superabundant fluid. One 
would naturally suppose, a priori, that bleeding from the 
veins would be most beneficial as the engorgement exists in 
them : and yet in some cases where blood could not be ob- 
tained from the veins, I have seen the best effects follow 



52 SCARLET FEVER. 

the abstraction of blood from the temporal artery. There 
seems an intimate sympathy, probably through the heart, 
between almost all trie blood-vessels, whether venous or ar- 
terial ; so that a certain impression made at some of the 
branches extends, like an electric influence, throughout all 
the vascular system. 

Whenever the practitioner bleeds in the highly conges- 
tive variety of the scarlet fever, he should keep his finger 
constantly upon the pulse, from the moment that the blood 
begins to flow: and if he should find it rising in force, he 
may be assured, that he may safely proceed to a moderate 
extent; but if, on the contrary, he should find it continue to 
sink, he must immediutely bind up the orifice. Venesec- 
tion should never be carried to fainting in great venous con- 
gestions. During syncope almost all the blood is accumu- 
lated in the veins ; and where there has been extreme op- 
pression before the bleeeing, throwing the patient into that 
condition might prove fatal. It most frequently happens 
in cases of this variety, that the blood at first merely tric- 
kles from the punctured vessel ; but the operator must wait 
for some time, and he will generally obtain a stream of 
blood at last. Many a life has probably been lost from 
bm4ingoip-the arm too soon, in examples of disease accom- 
panied with excessive congestions of venous blood. When 
there is a free return of blood to the skin after venesection, 
warm diluents will be the best drink that can be adminis- 
tered ; but when the skin remains cool after venesection, it 
will mostly be necessary to give the patient small and re- 
peated portions of warm wine and water, until some degree 
of arterial re-action succeed, and then diffusible stimuli of 
all sorts must be omitted. Immediately after the use of the 
warm bath, frictions, and bleeding, a large stimulating ca- 
thartic enema should be injected — an expedient which is 
more or less beneficial, not only by clearing the lower part 
of the bowels of their contents, but also by lessening the ir- 
ritability of the stomach. In conjunction with the means 
above mentioned, there is no agent with which I am ac- 
quainted, that tends to equalize the circulation in conges- 
tive cases so much as calomel ; and whenever it can be 
made by a bold administration to create a free, warm, and 
universal perspiration, with a copious flow of bile, the pa- 
tient may be generally considered out of danger. In the 



SCARLET FEVER. 53 

most formidable examples of the highly congestive variety 
of the Scarlatina, the secretion of bile is often totally sus- 
pended at the commencement; the liver being in a state 
precisely analogous to that which occurs in the worst in- 
stances of choiera morbus, so engorged with venous blood 
as to be incompetent to perform its wonted offices. All the 
instances of this modification of the scarlet fever which 
proved rapidly mortal, were designated by an absence of 
bile in the motions ; and the same has been the case in all 
the most concentrated attacks of cholera morbus, which 
have fallen under my inspection.* In both these affections, 
therefore, a plentiful flow of bile is a favorable ci '.cam- 
stance ; and I believe that few cases of the highly conges^ 
tive scarlet fever will end fatally where the hepatic secre- 
tion became copious and natural at the same time. As the 
stomach is generally very irritable in this form of the Scar- 
latina, the calomel must be given suspended in mucilage, 
and in eight or ten-grain doses even to children; and this 
quantity must be repeated two or three times within the 
first thirty hours — the short period in which the patient will 
be either saved or lost. If the calomel should not purge, 
it may be assisted by other cathartics, after it has been two 
or three hours in the intestines ; and where the stomach is 
exceedingly irritable, it may be advantageously exhibited 
with small doses of the camphorated tincture of opium, 
which accelerate its action on the skin, and do not retard 
either its specific or its purgative operation, both of which 
are requisite at the same time, that calomel may be emi- 
nently beneficial. 

If it were ever so much desired, it is a most difficult thing 
to excite ptyalism very early in children labouring under 
febrile diseases, but particularly when under those of the 
congestive class where the brain is disordered ; and it is 
not in general until the cerebral oppression be lessened by 
evacuations, that we see salivation take place. In ordinary 
complaints, ptyalism is one of the first obvious effects of 
mercury, but is often the last in those of an extraordinary 

* So far as ray observation and reading have extended, there is no 
author, ancient or modern, who has taken so correct a view of the na- 
ture of cholera morbus, as Dr. James Johnson ; and, considering* his 
illustration of that disorder among the most successful efforts in mudern 
pathology, I refer the reader to his valuable work on the Influence of 
Tropical Climates. 



54 SCARLET FEVER. 

nature : hence in the highly congestive scarlet fever we 
most frequently find the liver, kidneys, and skin excited by 
the calomel, while the salivary glands remain unaffected, 
unless it be continued when the general oppression is on the 
decline. The most certain test of calomel performing its 
intended office in congestive diseases is, the appearance of 
an universal excitement under its exhibition ; and if that 
action can be fairly established, every vestige of the previous 
and opposite one of venous congestion will soon be erased. 
Piyalism is certainly so far desirable in these cases, that the 
moment calomel begins to act as a salivant, we have distinct 
indications of re-action throughout the whole extent of the 
arterial system ; but it is prudent when that re-action has 
once been created prior to ptyalism, particularly if the skin 
be moist, not to exhibit calomel very largely, but rather to 
employ it moderately, in conjunction with cathartics. — 
Children at all times certainly suffer more from salivation 
than adults, and whenever it is excited in the former, it 
should claim an especial attention, that it may be at once 
moderated by purgatives and the tepid bath ; and, notwith- 
standing what some authors have asserted, I have never 
known an instance of ptyalism attended with the slightest 
hazard to children, where these precautions have been time- 
ly used. Mere salivation is at^no time to be considered as 
the principal part of the efficacy of mercury, yet it is one of 
the surest signs that it is operating on all the secretory or- 
gans of the body ; the conjoint evacuations elicited from 
them, and the return of the tide of the circulation into the 
arteries, being the means by which the local engorgements 
and the general oppression are relieved in congestive dis- 
eases. By instituting such a peculiar process through the 
agency of mercury, we only imitate the operations of nature 
when they are successful in throwing off such affections ; 
since when any organ is spontaneously freed from venous 
congestion, it is by an arterial re-action, and an augmented 
secretion. If the liver or lungs be overloaded with venous 
blood, the one is relieved by an arterial excitement and a 
flux of bile, and the other by an arterial excitement and an 
effusion of mucus into the bronchia ; as we have an exam- 
ple in point of the first in the disease called cholera morbus, 
and of the last in certain cases of spasmodic asthma. It is 
the local engorgements and the general oppression, in the 



SCARLET FEVER. 

highly congestive scarlet fever, which require calomel to he 
freely exhibited before it will act either as an aperient or as 
an alterative : and here we have another striking instance 
how disease modifies the operation of this medicine, even 
when the skin is not of a preternatural temperature. We 
must constantly bear in mind the state of the system at the 
time of prescribing calomel, otherwise we shall be liable to 
commit perpetual mistakes in its administration ; and it is 
chiefly from an inattention to this circumstance that it has 
been given with such dangerous freedom in some diseases, 
and in such feeble and ineffectual doses in others. Highly 
as I approve of a short and powerful course of calomel in 
certain acute complaints, my observations have deceived me 
much if this medicine be not greatly abused in chronic affec- 
tions ; and some practitioners I suspect have yet to learn, 
that it may be boldly and advantageously given for a short 
time under great oppressions, but that its long or profuse 
administration in many slow diseases, very frequently breaks 
down the system more than those diseases themselves. 

The blood abstracted is never covered with a buffy 
coat in the regular congestive form of the scarlet fever; 
and this is likewise the case in all diseases attended by sim- 
ilar conditions of the venous and of the arterial systems. — * 
The formation of what is called the inflammatory crust, re- 
quires general re-action and preter-natural heat ; and where 
these are absent in fevers, it will perhaps never be found. 
In some febrile cases, where general re-action and preter- 
natural heat existed, I have seen the blood drawn from a 
vein exhibit the buffy coat, while there was none upon that 
drawn from an artery ; although the operation had been 
performed nearly at the same time, so that the two currents 
flowed simultaneously. The blood circulating in the arte- 
ries is of a higher heat than that circulating in the veins even 
during health ; and the arterial blood requires a much high- 
er heat than the venous, to make it separate the inflamma- 
tory crust : hence we so often find this phenomenon upon 
the venous, and rarely upon the arterial blood. Yet the 
want of the inflammatory crust is no test of the impropriety 
of venesection, since it is absent in a most formidable class 
of diseases which imperiously require the lancet. When 
blood is drawn in the beginning of congestive affections, it 
tends to create a re-action in the heart and arteries* and 



56 SCARLET FEVER. 

this re-action if not restrained, sometimes passes on to in- 
flammation—an occurrence which explains the reason why 
there may be no buff upon the blood drawn the first day, 
and why it may abound in the second. Even the blood of 
persons in health may be made buffy by bleeding ; for less 
or more re-action generally follows that operation, where 
there was previously no increased excitement. These hints 
may tend to illustrate the changes induced by phlebotomy 
in venous congestions, such as are now the subject of in- 
quiry ; and they may also contribute to show with what 
care diffusible stimulants should be given in the commence- 
ment. 

In extraordinary cases of this nature, it is always best to 
bring all the most efficient remedies into action at the same 
time, as their collected, is invariably much greater than 
their individual influence. Acute diseases often readily 
yield to the rapid shocks of a prompt and powerful treat- 
ment ; whereas they will proceed in defiance of many fee- 
ble, protracted, and desultory efforts. In conformity to 
this doctrine, it has been my usual plan in the regular 
form of the congestive scarlet fever, to trust to one ge- 
neral blood-letting, in combination with the warm bath, 
frictions, tepid diluents, calomel, purgatives, and opium ; 
and besides these means, leeches and blisters have been 
sometimes applied. Having fairly tried the efficacy of such 
powers, within the shortest possible period, in a general 
way I attempt little more afterwards, than merely to assist 
the operations of nature by mild measures. It is perhaps 
too common an error in the practice of physic, to make 
trifling evacuations in the beginning of highly acute diseas- 
es, and to repeat them too frequently afterwards. Under 
this method the patient is bled or purged daily for some 
time ; but although the collective sum of the evacuations 
be very large, yet as each evacuation is separately small, 
the ultimate effect is, that the general strength is complete- 
ly consumed, and the disease remains unsubdued. Tepid 
drmks have been alluded to more than once as proper in 
the beginning of the highly congestive scarlet fever, and I 
must here add, that their power is greater than might ap- 
pear at first sight : they contribute to allay irritability of the 
stomach, to rouse the heart into action, and to determine 
the blood freely to the surface ; and on all these accounts. 



SCARLET FEVER. o? 

they are expedients, however simple, which ought never to 
be neglected in the outset. Sydenham stayed the vomiting 
in the plague, by exciting an universal perspiration • and if 
a copious and warm sweat can be early procured in the 
congestive forms of the Scarlatina, it will always be advan- 
tageous. 

In the first stage of the regular form oftfie congestive scar 
let fever, the energy of the system is not exhausted, it is only 
weighed down — the debility is not real, but merely appar- 
ent: there is then simply congestion of the venous system, 
and a consequent oppression of the powers of the heart and 
arteries. When, however, the first stage advances unimpe- 
ded, in the last an universal collapse always occurs, and is 
joined, not with venous congestions only, but also with dis- 
organization of some of the viscera. This view of the sub- 
ject may serve to illustrate the principles of treatment adapt- 
ed for each of these stages. Well-timed and judicious mea- 
sures may restore the balance of the circulation in the first 
stage, and insure a final recovery ; but every measure is 
precarious in the last stage, for what human agency can re- 
pair great lesions of structure ? With the exceptions al- 
ready stated, wine ought rarely to be given until the ap- 
proach of the last stage. Yet when the overpowering pres- 
sure of the internal congestions has been lessened by suffi- 
cient depletion, the occasional administration of a little Ma- 
deira wine is sometimes exceedingly serviceable, especially 
where the action of the heart and arteries has not become 
freely developed after venesection. As in the last stage it 
is sometimes impossible to determine precisely whether the 
danger proceeds from mere congestion and debility, or from 
congestion and organic lesion, wine is generally a remedy 
deserving of a fair trial ; whereas bleeding is then entirely 
inadmissible, and all evacuations, except moderate purging, 
must be carefully avoided. If there be organic lesion, wine 
will rapidly aggravate all the symptoms, and of course it 
should be withdrawn; if there be simple congestion with 
exhaustion, it will at least alleviate suffering, and occasion- 
ally prolong and even save life, particularly when exhibit- 
ed with small and repeated doses of opium, which will fre- 
quently be an useful auxiliary in alleviating the irritation 
attendant on the last stage. Indeed, in some cases of this 
variety, moderate or even large doses of opium will be found 

8* 



38 SCARLET FEVER. 

a sovereign remedy towards the close, when excessive irri- 
tation and debility exist without any organic lesion : and I 
cannot illustrate the utility of this drug better in such cases 
than to compare it to the effect which it produces in the last 
stage of cholera morbus, sometimes snatching patients from 
the very jaws of death. 

The better to elucidate the cure of this form of the scarlet 
fever, some cases shall now be concisely reported where the 
stimulant treatment failed, and some where the depletory 
succeeded. A numerous family of children was afflicted 
with the scarlet fever, when it raged epidemically, all of 
whom had the disease mildly except one boy, who was about 
five years old. From the attack he was overcome with op- 
pression, from which he never afterwards rose. On the first 
day his mind became confused, and in less than twenty-four 
hours he was almost indifferent to every thing around him. 
His pulse was feeble and quick, his breathing anxious and 
variable, and he vomited all that was administered. The 
efflorescence had a purplish shade, and was chiefly limited 
to the trunk ; the fauces were of deep dusky red, without 
an appearance of ulceration, and there was no preternatural 
heat on the surface, except about the abdomen. The tongue 
was white in the middle and moist, the stomach flatulent, 
and the belly somewhat distended. Early in the attack, his 
skin was well and frequently rubbed with flannels dipped in 
warm brandy ; but this expedient, which I have sometimes 
seen useful, did not induce any degree of re-action, and it 
was therefore abandoned. An antimonial emetic was pre- 
scribed, which acted repeatedly without producing the least 
good, nay the stomach became more irritable after its ope- 
ration. Calomel was next exhibited freely in mucilage, but 
as the greater part of it was rejected, the bowels were never 
copiously moved : the debility increasing apace, wine was 
liberally given, which however only seemed to increase the 
vomiting, and sink the strength more rapidly. The patient 
expired on the third day, covered with petechiae. Several 
hours before his death he passed his stools and urine invol- 
untarily, and the matter thrown from his stomach was dark 
as coffee, and had an offensive, sourish smell. On examin- 
ing the body after death, the throat did not appear to have 
been much affected ; but the brain and liver were found en- 
gorged with grumous blood. 



SCARLET FEVER. 59 

One Monday evening, a female child of a strumous habit 
was seized with chilness and vomiting, but making little or 
no complaint, was not attended to at the time. She lay 
tolerably tranquil during the night, and the next morning ap- 
peared to be in a dull, confused state of mind, indifferent to 
surrounding objects. About this time, a copper-coloured 
efflorescence came out partially on the trunk and extremi- 
ties, and medical advice was obtained. She had an emetic 
ordered, and after its operation a purgative, which moved 
her bowels freely. At no period did any preternatural heat 
arise on the skin. Under the cordial plan, she gradually 
sunk into a stupor, and died in convulsions on the ensuing 
Wednesday. In this case the principal congestion was most 
probably in the brain. The child was so quiet throughout, 
that she might have been deemed by a careless observer 
rather sleeping than dying, until the convulsions supervened. 
The above two examples may tend to prove the unavailing 
nature of the ordinary method of treatment, while the fol- 
lowing, as contrasts, will show the efficacy of bolder mea- 
sures. 

A boy in the seventh year of his age, who had been expo- 
sed to the contagion of the scarlet fever, became pale, lan- 
guid, sluggish, and oppressed. For the first day it was ima- 
gined that he merely laboured under the effects of a com- 
mon cold ; but on the morning of the second day, he was 
suddenly seized with a deep stunning pain in the head, at- 
tended with giddiness, oppressive nausea and retching, and 
anxiety about the prsecordia. In a few hours afterwards, a 
purple rash made its appearance on the upper part of the 
trunk and arms, and he complained of uneasiness in his 
throat, which on examination was found darkly inflamed. 
The heat on the centre was about the natural standard, but 
the extremities felt cool : the pulse was low and irregular, 
the tongue moist, the face pale, and indicating stupidity. — 
Ten grains of calomel and the same quantity of jalap were 
exhibited in mucilage, and repeated at the end of two hours ; 
and although both doses were retained, yet no evacuation 
followed. As the head evidently grew more disordered, 
and the general oppression greater, it was forthwith deter- 
mined to venture upon venesection. About six ounces of 
blood were accordingly abstracted from the jugular vein ; 
and shortly after the operation, the patient was immersed 



60 SCARLET FEVER. 

in a warm bath, and frictions applied to the skin. The good 
effects of this treatment were soon very manifest ; yet, with- 
out any loss of time, another dose of calomel was exhibited 
with jalap, and in about three hours, five or six very plenti- 
ful, dark, slimy, bilious stools were passed. From that pe- 
riod, there seemed a fair prospect of recovery, which was 
finally effected, through the agency of calomel and other 
purgative medicines. In this instance, the most palpable 
symptoms of congestion existed, especially in the brain ; 
but from the load at the stomach, and anxiety about the 
prsecordia, taken in conjunction with the appearance of the 
stools, there is reason to conclude that the liver was like- 
wise affected. 

An intelligent girl, in the tenth year of her age, who had 
previously been rather unwell, was attacked with the scar- 
let fever four days after exposure to the infection. The ef- 
florescence was of a dark colour, and receded soon after its 
appearance, although the throat remained permanently red 
and a little swollen. She referred her disorder to the head, 
heart, and stomach, where great uneasiness and oppression 
existed, which she could not distinctly define, but which she 
felt were the causes of all her suffering. The pulse was 
small and intermitting ; the breathing sometimes slow and 
interrupted, at other times short and hurried ; the stomach 
flatulent and distended ; and the mind apprehensive. A- 
bout nine hours from the occurrence of the urgent symp- 
toms, eight ounces of blood were taken from the arm, the 
patient was immersed in a warm bath, and frictions after- 
wards employed, as in the former instance. Considerable 
relief was obtained from this treatment ; but all the urgent 
symptoms were not decidedly overcome, until the liver, 
skin, and bowels had been freely excited by full doses of 
calomel, the warm bath, jalap, and the sulphate of magne- 
sia. In this and the preceding case, the cure was com- 
pleted within five days, and wine only late and sparingly ex- 
hibited, to ward off some appearances of debility which fol- 
lowed the depletion. 

The foregoing cases forming almost an epitome of my 
treatment in the regular form of the congestive scarlet fe-. 
ver, it seems unnecessary to swell these pages by bringing 
forward any more ; but injustice to the practice, I must ob- 
serve, that it has been equally successful in other severe ex- 



SCARLET FEVER. 6i 

amples. The depletory and alterative plan will succeed in 
many instances, if it be opportunely adopted, and properly 
pursued afterwards. Upon the whole, however, the regu- 
lar form of the congestive scarlet fever will be found gene- 
rally less manageable than any other modification of this 
disease. We have still much to learn respecting the phe- 
nomena, nature, and treatment of the congestive varieties 
of fever in general, and I know of no department of medical 
science which is more deserving of universal attention. — 
Would the inhalation of oxygen, or of some other invigora- 
ting gas, be serviceable in the outset, by directly communi- 
cating power to the heart, and thereby tending to restore the 
lost equilibrium of the lost circulation ? Would heated va- 
pour do good, applied to the whole surface, and followed by 
frictions of oil to excite sweat, after the manner commonly 
used by the Asiatics ? Would any advantage be derived from 
mercurial fumigations, or from the employment of electrici- 
ty — the first as a rapid salivant, and the last as an immedi- 
ate excitant of the heart and arteries ? These questions may 
be answered hereafter, and they are put here, not positive- 
ly to recommend the agents specified to an actual trial, but 
merely to suggest them as probably deserving of considera- 
tion : for certainly there is no class of diseases, the cure of 
which is enveloped in more obscurity, than that of conges- 
tive fevers ; and it is anxiously to be wished, that inquiry 
may be concentrated upon a point which, from its great im- 
portance, needs an immediate illumination. 

While these sheets were passing through the press, I re- 
ceived the following case from Dr. Howell of Clifton. It 
remarkably illustrates the great efficacy of blood-letting in 
a highly congestive form of the scarlet fever, and is there- 
fore inserted here, in the precise and impressive language of 
that enlightened physician. After a long march in wet wea- 
ther, a lieutenant, of rather a full habit, aged 1 8 years, was 
seized with Scarlatina, and the eruption receded on the sec- 
ond day. He grew gradually worse ; delirium came on, 
followed by subultus tendinum to an alarming degree, and 
he picked the bed-clothes, and raved incessantly for four 
nights and three days. A dozen leeches had been appied 
to his head previous to the occurrence of the delirium, and 
the cold affusions and purgatives had been resorted to in 
vain. 



62 SCARLET FEVER, 

In this almost hopeless state, the pulse evidently sinking, 
and the action of the heart scarcely to be felt, the temporal 
artery was opened, as the most rational, and only chance of 
relief. For some time the blood scarcely trickled down 
his cheek, and the motion of the artery was not perceptible. 
In a few minutes, however, the pulsation became evident ; 
the artery seemed every instant to be regaining its strength, 
and the blood was at last thrown to the distance of a foot 
or more. So instructive a lessen could not be disregarded : 
and to have bled by ounces, continues Dr. Howell, might 
have terrified us before relief was half obtained ; we there- 
fore persevered until the circulation was relieved, and the 
heart more equable in its action. The young man become 
more tranquil, and in a few hours fell into a profound sleep, 
which lasted nearly twenty-four hours. He awoke from 
every symptom and recovered in the most rapid manner. 
The blopd taken away weighed fifty-three ounces and a 
half. 

This case, I must add, may be paralleled, but cannot be 
surpassed in interest ; and no lover of medical or of human 
nature can peruse it without a feeling of admiration towards 
the man who suggested and applied the remedy. Under 
such circumstances, most practitioners would have had re« 
course to diffusible stimulants, and the patient would have 
perished from the congestion, and from the practice pursu- 
ed. In all probability there was a load of blood about the 
right side of the heart, which had occasioned congestion in 
the brain, and other parts, by retarding the return of ve- 
nous blood ; but the determined abstraction of so much of 
the vital fluid brought the heart again into play ; and the nat- 
ural balance of the circulation was fortunately once more re- 
stored. From instances of this nature one would suppose, 
that the action of the heart extends even throughout the 
venous system ; for when that action is nearly suppressed, 
the blood is almost stagnant in the veins ; and when it is 
fairly renewed, the blood flows freely from the punctured 
vessel. But waving all speculation in such case, it may be 
held up as a practical example of superior skill for others 
to imitate, where great congestion exists in conjunction 
with that semblance of debility which has so often deceiv- 
ed practitioners into the fatal employment of excitants. 

During convalescence from the congestive varieties of 



SCARLET FEVER. 63 

the scarlet fever, dropsical effusions are very apt to appear, 
unless great care be taken to preserve the surface from cold, 
to keep the bowels regular, and to avoid the exhibition of 
diffusible stimulants. For sometime after the removal of 
the congestions, there is a considerable relaxation of the 
general habit, combined with an irregular disposition to ar- 
terial excitement ; and any cause which increases this dis- 
position, may occasion an internal or an external dropsy* as 
the absorbent system seems unequal to counterbalance any- 
excess of the secretions. Indeed, similar precautions to 
those above stated, ought always to be taken after the de- 
cline of all the various forms of the scarlet fever : for even 
in those accompanied with an increase of heat and of ex- 
citement, dropsy is a sequela not unfrequently observed. 
The excessive excitement of the capillary arteries in such 
affections, occasions an ultimate loss of tone in the extrem- 
ities of those vessels ; so that the secretory organs seem to 
admit of a sort of serous tranudation, from the augmented 
impetus of blood which succeeds the stage of collapse, and 
which accompanies convalescence. But independently of 
these particulars, there is frequently a tendency left to in- 
creased actions about the viscera on the retrocession of the 
scarlet fever : and hence we sometimes see hydrothorax, 
ascites, or the affection called hydrocephalus, follow this 
disease, in combination with clear marks of increased ac- 
tions in the regions where they are seated. In every point 
of view, therefore, the common practice of administering 
excitants during convalescence is most exceptionable. An 
effort of nature to restore the strength always follows fe- 
brile diseases, and that effort is of itself sometimes so great 
as to require to be restrained by moderate evacuations ; 
but where it is elevated by measures exciting the heart and 
arteries, it produces determinations of blood, which lead 
to dropsical effusions, or to inflammations of the viscera. 
Even the diet should be mild for sometime after the abate- 
ment of acute fevers ; and on this account, milk is one of 
the best articles of food, as it supports the strength, with- 
out irritating the nervous, or stimulating the vascular sys- 
tem. 

When in attendance, some years ago, upon a family in 
which the scarlet fever existed, I was requested to look at^ 
a boy who had just sickened, for whom I prescribed a lax- 



64 SCARLET FEVER. 

ative, and a mild emetic afterwards, as the symptoms were 
then apparently slight ; but early next morning I received 
an urgent message to visit him, and to my surprise found 
him expiring under coma and convulsions. The severe 
congestive symptoms had come on soon after I left the 
house the preceding day, and his parents deeming them 
nothing more than precursory signs of the fever, did not 
give me timely information of the change ; and thus the 
delay of a few hours was to them an irretrievable loss, and 
to myself the occasion of the deepest regret. Other ex- 
amples of a like insidious nature have come under my 
observation, and they seemed utterly inexplicable, un- 
til I had obtained some morbid examinations ; and then the 
manifest mischief of the visceral congestions, and the con- 
sideration of the previous symptoms, enabled me to com- 
prehend their pathology. Acquainted with such impressive 
facts, I never afterwards saw any child sickening of the 
scarlet fever, to whom I did not pay the most assiduous at- 
tention ; and I would strenuously advise every practitioner 
to be most circumspect at that early period ; for then, by 
proper depletion and the warm bath, he may often prevent 
the accession of highly congestive symptoms, or remove 
them when just coming into existence. The throat of chil- 
dren should be examined daily wherever the scarlet fever 
prevails; and some preternatural appearance there will 
frequently indicate the approaching distemper, before any 
complaint be made. But this is more especially the case 
when adults are under the influence of the contagion of 
the disease ; and in them I have seen the peculiar slough 
in the fauces attended by a typhoid sort of fever, without 
any efflorescence upon the surface of the body. 

Before concluding the subject of scarlet fever, it ought 
to be noticed, that most of the older authors are for, and 
most of the later against, depletion in the malignant forms; 
so various are the records of human opinion, even on mat- 
ters of vital importance. The theories of medical men 
are constantly changing, but diseases have always been un- 
der the same influences ; as the planets revolved by the 
same laws, whatever conjectures were framed respecting 
them in the lapse of ages. The opinions of men may vary, 
but the operations of nature are unchangeable. The three 
powers which affect disease, independent of the physician. 



SCARLET FEVER. 68 

are — the cause^ the circumstances under which that cause 
is applied, and the condition of the subject upon whom that 
cause and those circumstances operate. Now one and the. 
same cause always produces similar effects ; and though the 
effects are modified by peculiarities of places, of seasons, 
and of patients, yet still they are reducible to varieties 
which observe regular laws ; and if those varieties had al- 
ways been marked and separated with sufficient care, in- 
stead of having been confounded in general descriptions, 
what now seems a chaos in physic would have presented 
an harmonious arrangement. One very remarkable exam- 
ple might be adduced, to show how the same cause pro- 
duces different, yet ascertainable varieties of disease, and 
that is the miasm arising from damp or marshy grounds : 
in one person it occasions an intermittent, in another a re- 
mittent, and in a third a continued fever,* according to the 
place where it originated, or to the habit in which it oc- 
curred ; and notwithstanding these types of fever differ 
among themselves, yet singly considered, they are subject 
to a surprising uniformity of character. Only attentively 
examine the effects produced by any other specific cause 
of febrile disease, and- it will be satisfactorily discovered, 
that each of them admits of a similar uniformity ; and in- 
deed it is by ascertaining the nature of each of these effects, 
that we are principally enabled to deduce precise rules of 
treatment. It has lately become the fashion to suppose 
that some diseases have changed their character in our 
times ; but perhaps it would be much more correct to say, 
that our pathology and treatment of them have become 
more perfect. With respect to febrile diseases in partic- 
ular, the various tissues attacked by inflammation or con- 
gestion necessarily give a diversity of appearance, inde- 
pendent of merely external signs \ but still it is, generally, 
inflammation or congestion, and as such requires to be trea- 
ted according to its degree, and to the habit in which it oc- 
curs. The laws of living bodies and of inert matter are 
most manifestly different, and vital are more varied than 

* Dr. Cullen has excluded from his definition of the Continue, fe- 
vers which arise from marsh effluvia, or if they did not occasionally as- 
sume the continued type. But in the common systems of nosology, 
we constantly find diseases, not arranged according to their natures, 
but according to the theories of the respective writers. 
9* 






66 SCARLET FEVER. 

physical phenomena in kind and degree ; yet if we were 
as well acquainted with vital as we are with physical laws, 
we should probably find a similar uniformity in their na- 
ture. Even the epidemical influences of the atmosphere 
upon the human body, like the constitutional peculiarities 
of individuals, seem to be limited in their modifications of 
disease, though those modifications and those peculiarities 
have not yet been well arranged. 

How then, it may naturally be asked, has it come to pass 
that so much discrepancy of theory and of treatment should 
exist concerning febrile diseases ? There is a tendency in 
the human mind rather to search after the abstract essences 
of things, than to collect, arrange, and exhibit their phenom- 
ena as presented by nature ; and this tendency, it cannot be 
fairly denied, has operated as powerfully in medicine, as in 
any other department of scientific inquiry. Hence, since 
Hippocrates, comparatively few have minutely noted either 
the varieties or the stages of particular fevers, either the pe- 
culiarities which surrounded, or which existed within pa* 
tients ; and hence, too, the labours of innumerable practi- 
tioners have been unproductive of good, from an implicit 
reliance upon the hypothesis of some ingenious predecessor 
or cotemporary. One conjecture or other, relative to the 
scarlet fever, has exerted a manifest influence over most of 
those who have written on the subject ; so that their re- 
spective opinions are coloured by the doctrine of the day, 
as rays of light are tinged by the medium through which 
they pass. But so far as my reading extends, all those wri- 
ters who decidedly condemn depletion, either do so on the 
vague authority of others, or from having themselves used 
it partially in the first, or seen it destructively hazarded in 
the last stage. Indeed, a singular confusion exists both in 
the descriptions and in the opinions of almost all the writers 
who protest against venesection ; for not only do they blend 
the symptoms of the first and the last stages together, but 
carry their prejudices so far, as to censure purging with the 
most indiscriminate zeal. It were to be wished, that they 
had at least paid more attention to the stages ; for it is upon 
this point that all the difficulty, that all the discrepancy 
turns, in the treatment of the malignant varieties. Let one 
man, called very early, pursue the depletory plan, and he 
will save the greater part of his patients ; let another, cal* 



SCARLET FEVER. m 

led late, pursue the same method, and he would lose every 
patient. It is for want of having discriminated the stages 
that those authors have erred in their own practice — it is 
for want of having discriminated the stages, that they have 
unconsciously misled the public through their literary pro- 
ductions. The late most excellent Dr. Fothergill, who so 
powerfully advocated the doctrine of debility in his popular 
essay, changed his sentiments when his experience became 
matured ; for a little before his death he confessed to Dr. 
Withering, that he had long been dissatisfied with the treat- 
ment of the scarlet fever, and that in prescribing bark he 
had rather yielded to the opinions of others, than followed 
the suggestions of his own judgment.* Those authors were 
successful who used depletion early, and those failed who 
used it late ; and thus they arrived at different conclusions 
respecting the same measure, because it was employed un- 
der circumstances essentially different. But we are coming 
fast round to the old practice ; for purgative medicines, 
through the agency of Dr. Hamilton, are now universally 
employed in the Scarlatina Anginosa ; and if to this method 
that of the cold and warm affusions be added, we shall per- 
haps find the treatment of no modification of disease so much 
improved in modern times. The result is felt every where. 
Practitioners acknowledge, that the scarlet fever has become 
far less fatal since the introduction of these measures ; and 
there is no denying the assertion, since the Scarlatina Angi- 
nosa is by far the most common form of the disease. But 
though the malignant varieties of this affection are fortunate- 
ly of the least frequent occurrence, yet we must still expect 
them occasionally to return, and should be prepared to en- 
counter them with a promptitude and decision suitable to 
their extreme urgency. 

In bringing my observations to a close, I must once more 
repeat, that as the partial application of the active means 
recommended would not answer in the early stages of the 
highly malignant scarlet fever, so their use in the last would 
be inevitably mortal ; and I must, therefore, earnestly cau- 
tion those who may hereafter try them, alike to avoid their 
partial and their late employment. Suppose any practition- 

* See p. 10, of An Account of the Scarlet Fever and Sore Throat, 
The Second Edition. By William Withering, M. D. F. R, S. Bir 
mingham. 1793* 



68 SCARLET FEVER. 

er were to use one very partial affusion of cold water in the 
excitive stage of the Scarlatina Anginosa, or rashly to ven- 
ture upon its general and repeated application in the last 
stage of collapse, it must be apparent that no correct infer- 
ence could be drawn as to the powers of that physical agent, 
because it was only partially employed in the first stage, and 
upon mistaken principles in the last. The same mode of 
reasoning may be extended, with equal justness, to the use 
of venesection and purgatives in the malignant scarlet fever : 
if they be partially tried at an early period, they will hardly 
ever succeed ; and if they be rashly used in the last stage, 
they will be generally mortal. In a word, their general 
efficacy is only to be ascertained by their fair and decisive 
employment from the beginning of the disease. As far as 
our information extends, we find a wonderful uniformity in 
the laws which regulate particular diseases, especially those 
referrible to the class pyrexiae. But authors have frequent- 
ly neglected to mark with precision the stages and symptoms 
which prevailed at the time that their different remedies 
were applied : and we well know what confusions and con- 
trarieties a neglect of such particulars may occasion in pa- 
thology and therapeutics. In remote ages, the yellow fever 
of warm climates was treated chiefly by depletion. That 
disease, however, having been considered in our times as a 
true typhus icterodes, depletion was abandoned, and the sti- 
mulant practice introduced, for which some able advocates 
arose, who seemed confident of its superiority. Yet a more 
extended and minute inquiry discovered the utter inutility 
of stimulants in the first stages, and they were also aban- 
doned. Depletion was once more tried ; but being in gen- 
eral too sparingly or too late employed, doubts and embar- 
rassments again arose as to its propriety. Repeated ob- 
servations, however, and morbid dissections, having clearly 
demonstrated, that the worst forms of the complaint are 
highly inflammatory or highly congestive, evacuants were at 
length early and decidedly used, and they have been found 
better than any other means, when promptly aided by cal- 
omel. The period, too, is fast approaching, when the con- 
joined or separate use of wine and bark, the extreme unc- 
tion of timid practitioners, will be deemed as pernicious in 
the first stages of the malignant scarlet fever, as they are in 
those of the yellow fever : and when the superiority of ear- 



SCARLET FEVER. 69 

ly depletion will be as firmly established in the one as it 
has been in the other. Perhaps there is more analogy be- 
tween the highly congestive and inflammatory forms o: the 
yellow fever and of the Scarlatina than might be supposed 
at a first view ; and as the former are sometimes fatal under 
the best practice, so will be the latter ; and it is only by 
comparing the general results, that we can establish in both 
the superiority of the evacuant over the stimulant treatment. 
It is in physic as in morals— the expediency of any thing 
which we do is not to be correctly ascertained by its eiiects 
in a particular case ; for we must trace it through its gen- 
eral consequences before we can arrive at just inferences 
respecting its operation. 

The most violent instances of the malignant scarlet fe- 
ver, which were treated by wine and bark from the com- 
mencement, ended mortally in my practice ; and it was the 
want of success which at first led me to doubt, and at last to 
disregard the scholastic doctrines which had held my mind 
in subjection. The purgative mode of cure was, therefore, 
substituted ; and though it very often relieved for a time, 
yet it rarely succeeded in the end. Inquiring into the cause 
of such failures through morbid dissections, I found that they 
proceeded from local inflammations or local congestions. 
So important a truth being «bnce fairly known, venesection, 
calomel, and other purgatives, were promptly used at the 
onset of such cases. This treatment, with the occasional 
aid of stimulants, answered my most sanguine expectations 
in many instances; though, as already stated, it did not 
succeed in some, and it would be unreasonable to expect 
that it should hereafter be always efficient. There are ex- 
amples of highly acute fevers, from whatever source arising, 
which set all applications at defiance ; the attack being so 
concentrated, and the progress so rapidly destructive. But 
happily, such cases are comparatively rare in this country ; 
and it is my firm persuasion, that most of our worst fevers 
may be arrested at the first attack, by right treatment. At 
the same time we must be careful to discriminate the cha- 
racters of the affections for which we prescribe ; since, 
though it may be dangerous to delay active means in some 
varieties, it is highly injudicious to employ them in all. — 
Practitioners of experience must have observed, that the 
scarlet fever is sometimes so mild a disease, as hardly to re- 



■ 



10 SCARLET FEVER, 

quire any medicines ; that at other times it is more strongly 
characterized, though still readily controllable by purga- 
tives and the cold or tepid affusions ; and that it is also oc- 
casionally so violent from the beginning, as to render the 
agents commonly used quite unavailable. All these cir- 
cumstances must, therefore, be borne in mind, that the re- 
medies may correspond to the different appearances which 
the disease assumes. It is in the severest forms, and in 
them only, that extraordinary measures are required ; and 
to extend those measures to other forms, would be a per* 
version of the principles laid down in these pages. 



PULMONARY CONSUMPTION. 



BY pulmonary consumption is now generally understood, 
a disease dependent upon tubercles seated in the cellular 
connecting membrane of the lungs ; but under this title it 
would appear, that different diseases have not unfrequently 
been included in medical writings. The more effectually 
to clear the subject from obscurity, it should be noticed, 
that four affections may be mistaken for the tubercular 
phthisis, even when they occur in their least complicated 
forrhs ; and these affections are, namely, chronic inflamma- 
tion of the bronchia, ulcerations in the trachea, chronic in- 
flammation of the pleura, and lastly, chronic and simple in- 
flammation of some portion of the lungs themselves, A few 
concise remarks, therefore, shall be made on each of these 
in their simplest states ; and it will afterwards be shown, 
how they may be combined with the tubercular or genuine 
phthisis itself. 

Chronic inflammation of the bronchia is sometimes the 
sequela of an acute attack of pulmonary inflammation : at 
other times it arises out of a common and neglected catarrh 
in irritable or debilitated habits, or follows an acute attack 
of bronchial inflammation ; and occasionally it is connected 
with a disorder of the liver, or of some other distant organ. 
When it exists alone, the symptoms resemble those of an 
ordinary catarrh for some time ; and most frequently the 
attention of the practitioner is only excited seriously by 
their continuing unabated, when they might have been na- 
turally expected to decline. On a close examination, 
however, the pulse will be found quicker than natural, more 
especially towards the evening, and the heat of the skin at 
that time rather above the usual standard, though it varies 
in the course of the day, and is sometimes below the natural 
standard. These circumstances, together with the dura- 



72 



PULMONARY CONSUMPTION. 



tion and increase of the cough, the frequent expectoration 5 
and the somewhat uneasy nights, for the most part warn us 
of the establishment of chronic inflammation of the bron- 
chia. Frequently there is some feeling of soreness, or of 
weight in the chest, and occasionally a transient stitch 
through the side, but scarcely ever any fixed pain within 
the breast. The patient can generally take full and repeat- 
ed inspirations without pain, and lie equally well on both 
sides, though the horizontal posture usually renders the 
breathing more uncomfortable, as well as the cough more 
troublesome for a time ; and a request is generally made 
to raise the upper part of the bed by pillows, that the shoul- 
ders and the head may be elevated during sleep. Never- 
theless, I have known some patients who found relief from 
the recumbent posture, on account of the expectoration 
being then more abundant. The expectoration, however, 
is the greatest, and the cough the most urgent in the morn- 
ings, when there is usually considerable wheezing, until the 
phlegm is dislodged which had accumulated in the night. 
More or less coagulable lymph is almost always spit up 5 
sometimes in long thready pieces, but mostly in small glut- 
inous lumps. Yet I have a remarkable preparation of this 
substance, which was expectorated by a young woman : it 
consists of two separate, soft, solid branches, spreading into 
many ramifications. The following is a sketch of both as 
they came moulded from the bronchia. In the majority of 




cases, the sputa are at times mixed or streaked with blood, 
which comes from the small vessels of the bronchia ; and at 
first they are often glairy, somewhat like the white of an egg. 
they grow opaque as the disease advances, and at length be- 



PULMONARY CONSUMPTION. 73 

come really purulent. When this chronic inflammation is 
protracted, and when pus is copiously expectorated, it is at- 
tended with nearly as much emaciation and debility as the 
tubercular consumption ; but it sometimes happens that it 
is not thus protracted, the supervention of an acute inflam- 
mation unexpectedly carrying off the patient. Where it 
proceeds to an advanced stage, it will mostly be difficult, if 
not impossible, to distinguish it from the tubercular con- 
sumption, particularly when it has caused an abscess in the 
lungs themselves. During the early stage, however, it may 
be recognized by the wheezing and catarrhal character, by 
there being less wasting of the flesh and strength than in the 
tubercular consumption, by the concomitant fever then no! 
assuming the true hectic type, and by the patient being able 
to draw the breath deeply without uneasiness. From the 
commencement there is indeed some fever, but night- 
sweats rarely take place until the expectoration become- 
purulent 5 though the skin is occasionally moist and cold in 
some parts during the remission of the pyrexia. The face 
has generally a sickly pallidity in the onset and progress of 
chronic inflammation of the bronchia, and the lips a leaden 
or bluish hue ; whereas in the tubercular consumption the 
colour of the face comes and goes, and the lips are common- 
ly Jinged with a beautiful bright red. In the beginning of 
ydironic inflammation of the bronchia, the hands and feet 
are often cold, and the temperature of the surface altogeth- 
er more variable than in the tubercular consumption ; and 
though at that stage of the former, the patient may often 
pass uncomfortable and unrefreshing nights, yet upon the 
whole he obtains longer sleeps at intervals than in the latter. 
From the commencement of chronic inflammation of the 
bronchia there is most frequently some degree of inflam- 
mation in the upper portion of the pharynx; but that in- 
flammation also partakes of the chronic character through- 
out, the part being of a pale red, over which the veins are 
dispersed of an unnatural fulness, an appearance almost 
pathognomonic of chronic inflammation. The cough i^ 
generally short, tickling, and dry, in the beginning of the 
tubercular consumption, when uncombined with any other 
disease ; whereas in this form of chronic inflammation of 
the bronchia, the cough is deep, and the expectoration free 
almost from the first, and continues to be copiously blended 
with mucus to the last. There is more stuffing, too. about 

10* 



74 PULMONARY CONSUMPTION. 

the lungs in the commencement of chronic inflammation of 
the bronchia, and the expectoration affords more alleviation 
to the cough. It is, besides, accompanied with a greater 
load, though with less pain in the thorax 5 and much less 
cough generally occurs from a full inspiration, or from turn- 
ing on either side, than in the tubercular phthisis. But 
when chronic inflammation of the bronchia is combined with.r- 
an affection of the liver, or of some other abdominal organ, 
the patient in general can only lie with any degree of com- 
fort on the right side, or flat upon his back. The quantity 
of the expectoration, the character of the fever, and the 
other circumstances before enumerated, will enable the 
practitioner in the onset, and in part of the advancement. 
to distinguish this combination of complaint from the tuber- 
cular consumption ; while the furred tongue, the foul breath, 
the unnatural stools, the capricious appetite, the distended 
epigastrium, and the uneasiness which generally attends 
pressure on some part of the abdomen, will sufficiently 
mark it from the simple chronic inflammation of the bron- 
chia first described. Both these varieties of disease may 
arise after the measles from the influence of cold, or from 
some disorder in the digestive organs : but they are like- 
wise not uncommon after other affections, which predispose 
the lungs and the liver to increased action ; and they may 
sometimes be directly traced in delicate habits to vicissi- 
tudes of the weather, or to errors of diet and too light 
clothing. It has been one of the most striking peculiari- 
ties in several cases of the epidemic fever which has pre- 
vailed this year in London, that, with whatever symptoms 
they might commence, the mucous membrane of the bron- 
chia has become at last acutely inflamed ; and" even where 
the acute inflammation has been arrested, it has in some in- 
stances left a disposition to chronic inflammation of the 
bronchia, which occasionally has been complicated with 
hepatic disease. 

Dr. Young, in a treatise equally distinguished for talent 
and learning, has mentioned a very simple and good criteri- 
on of pus. If a little of the substance to be examined, he 
informs us, be put between two pieces of plate glass, and, 
while held near the eye, looked through at a distant candle, 
Ave shall observe, even in the day time, a bright circular 
corona of colours, of which the candle is the centre ; a red 
area being surrounded by a circle of green, and this again 



PULMONARY CONSUMPTION. 15 

by another of red, the colours being so much,brighter as the 
globules of pus are more numerous and more equable. If 
the substance, however, be simply mucus, there will be no 
rings of colours 5 although sometimes there is a sufficient 
mixture of heterogeneous particles, even in mucus, to cause 
a reddish area alone. * But, how useful soever this test 
may be on some occasions, it will not enable us to distin- 
guish bronchial inflammation from phthisis, since pus is 
alike expectorated in both; and we must therefore have 
recourse to the rise, progress, and general character of the 
symptoms, to enable us satisfactorily to make the diagnosis. 
At the termination of pure chronic inflammation of the 
bronchia, the capillaries in the mucous membrane of those 
parts will be found preternaturally injected with blood, and 
the branches, if traced accurately, filled with pus and mu- 
cus. 

An ulcer in the trachea may be a consequence of the 
preceding disease, in which there is generally more or less 
of increased action on the lining of that part, extending from 
the bronchia ; but it is oftener the result of a separate and 
insidious inflammation, which arises from various causes, 
and which at first is denoted by little more than a tickling 
cough, slight change of voice, obscure uneasiness in some 
portion of the trachea, occasional oppression in the breath- 
ing, and a slow increasing fever. Slight traces of inflamma- 
tion often exist at the same time, about the pharynx or the 
tonsils. In the primary stage of the tracheal inflammation, 
mucus and lymph only are expectorated ; yet as soon as 
ulceration takes place, the sputa are mixed with pus, though 
in general neither the first nor the last be so abundant as in 
simple chronic inflammation of the bronchia. Some de- 
gree of lassitude and a gradual loss of flesh are now observ- 
able, and the functions of the stomach and of the liver not 
unfrequently become disturbed. In the progress of the ul- 
ceration, the breathing grows more uneasy, the voice thick- 
er, and the cough much more troublesome ; besides, the 
patient passes restless nights, and labours under a more 
manifest fever than before, though it is seldom attended 
with copious sweats, as in the regular hectic. The body 

* See p. 27 of A Practical and Historical Treatise on Consumptive 
Diseases. By Thomas Young, M. D. &c. London, 181S. 



7(J PULMONARY CONSUMPTIQI*, 

continues to waste, the pulse to rise in frequency, the skin 
has a sallow, faded hue, and the face is for the most part 
pale throughout, except when transiently flushed by a fe- 
brile paroxysm ; but there is rarely the circumscribed patch 
of bright red on the cheeks with the glistening eye, observ- 
able at the exacerbation of the hectic which attends the tu- 
bercular consumption. The expression of the countenance, 
too, is generally more anxious at times than in the last men- 
tioned disease, the spirits more depressed, the mind more 
irritable, the respiration occasionally more disturbed, and 
yet no fixed pain in the chest ; although an undefinable 
weight or load is not unfrequently felt near the middle or at 
the lower part of the sternum, and a hoarse sort of noise is 
commonly made on taking a deep inspiration. Considera- 
ble remissions sometimes take place in this disease, so that 
one might anticipate recovery ; but these are almost always 
fallacious, the symptoms generally returning with increased 
severity. In some cases, life is prolonged three, four, five 
months, or even longer, and in others it is suddenly extin- 
guished by an acute attack, resembling the croup or pneu- 
monia. Two cases bearing the characters of ulceration in 
the trachea have occurred in my practice, after the measles, 
and the subjects of both were manifestly of the strumous 
temperament. One severe instance I likewise witnessed 
in an old man, apparently proceeding from a large external 
tumour, which had long pressed upon the wind-pipe : and 
a few others have been presented to me, which originated 
from cold, or from the hooping cough, and some which 
were connected with the secondary symptoms of syphilis. 
Of the latter description I have known two examples treat- 
ed* as pseudo-syphilitic, under an impression, that all the 
symptoms resulted from sympathy with the digestive or- 
gans, which were certainly disordered ; but so far from be- 
ing the cause, an accurate inquiry tended to prove, that 
the disordered condition of the digestive organs was one of 
the effects of the local irritations, and of the general influ- 
ence of the venereal virus. There cannot be the least 
doubt that certain local affections, originating from distur- 
bances in the digestive organs, do actually attack the same 
or similar textures as the secondary syphilis ; but that these 
local diseases, taken in all their bearings and extent, as- 
sume the genuine characters of syphilis, is a proposition 



PULMONARY CONSUMPTION, 77 

contradicted at least by the facts which have fallen under 
my own observation. The work of Mr. Abernethy, on the 
constitutional origin of local diseases, is generally allowed 
to be one of the most valuable which modern times have 
produced; and if called upon to give an opinion respecting 
it, I should say, in the language of Bacon, that it deserves 
to last as long as books last.* Yet I cannot but think, that 
the particular applications of the general principle of the 
constitutional origin of local diseases, require the utmost 
care and discrimination ; and I am fully convinced, that 
from an alliance with this excellent principle, the specious 
doctrine of pseudo-syphilis has gained an unmerited ascend- 
ency over the minds of many practitioners. But, no long- 
er to digress from the original subject, it may be remarked, 
that when an ulcer in the trachea is venereal, the real na- 
ture of it may be inferred from the other secondary symp- 
toms of syphilis which are manifest at the same time, as the 
peculiar , deep sore in the throat, the copper-coloured spots 
on the skin, or the like ; and where such symptoms have 
been absent throughout, the ulcer will almost always be 
found to have proceeded from an inflammation of a differ- 
ent kind. The most distinguishing mark of ulceration in 
the trachea is pain, soreness, or some species of uneasiness 
referred to a particular part of the wind-pipe, in combina- 
tion with purulent sputa. But before the ulceration takes 
place, a local uneasiness, increased by pressure, often marks 
the existence of a chronic inflammation : and it is of great 
consequence to attend to this, as it is at first sometimes so 
slight or so obscure as hardly to arrest the attention of pa- 
tients, who even then in general spit up some pieces of 
lymph occasionally. It was chiefly by attending to the lo- 
cal uneasiness, that Morgagni detected an ulceration of the 
trachea in a person of distinction, and from this case he in- 
forms ue, that he obtained great reputation when a young 
man ; indeed independently of the minute and accurate de- 
tail of this interesting case, no author has given a better ac- 
count of the causes and character of ulcerations in the 
windpipe.t 

* See Lord Bacon's Dedication to the Duke of Buckingham, prefix- 
ed to his Essays, Moral, Economical, and Political. 

f Consult the 22d Letter, in the 2d Book, of Morgagni on the Caus- 
es and Seats of Diseases, investigated by Anatomy. 



78 PULMONARY CONSUMPTION. 

Dr. Bailie mentions, in his excellent work on morbid 
anatomy, that the pleura appears to be more liable to in- 
flammation than any membrane lining those cavities which 
h,ave no external opening. In confirmation of this he noti- 
ces, that the chest of any patient, who had arrived at an 
adult age, can hardly be examined, without some traces of 
a recent or of a past inflammation being found ; and he ju- 
diciously accounts for the circumstance, by the free com- 
munication of blood-vessels between the external and inter- 
nal parts of the thorax, by the cold and variable nature of 
our climate, and by the manner in which the breast is so 
much exposed, by our dress, to the influence of the atmos- 
phere.* If such important observations as these had been 
more generally regarded, it is highly probable that chronic 
inflammation of the pleura would not have been unnoticed 
in the various divisions of our nosologists : indeed I know 
of no author who has written expressly on the practice of 
physic, by whom this disease has been described, with the 
exception of Baglivi, and his account is very concise. Pleu- 
risies, he informs us, are frequently unperceived, because 
they are painless ; and this occasions gross mistakes in prac- 
tice. In order, he continues, to discover these occult and 
indolent pleurisies, make the patient lie down on his right 
or leftside : after he has inspired with force, and coughed 
once or twice, ask him if in breathing or in coughing he felt 
no pain or heaviness in any part of his breast; and assure 
yourself, that a pleurisy is seated in that place where he 
feels the pain or the heaviness. He concludes by observ- 
ing, that he has benefited many patients from the discovery 
of pleurisies in this way : t and certainly his directions, in 
a diagnostic view, are very judicious, and ought to be fol- 
lowed in all obscure cases. 

Chronic inflammation of the pleura, according to my ob- 
servation, is not uncommon. When the more acute forms 
of pleuritis are apparently subdued, a low, obscure kind of 

* The Morbid Anatomy of some of the most important Parts of the 
Human Body. By Matthew Baillie, M. D. F. R. S. &c &c. The. 
third Edition, corrected. Seep. 49, 50. London, 1807. 

f The Practice of Physick Reduced to the Ancient Way of Obser- 
vations, &c. Written in Latin, by Geo. Bag-livi, M. D. Professor of 
Physick and Anatomy at Rome. The second Edition. See p, 64. 
•London : printed fpr D. Midwinter. 1 7253i 



PULMONARY CONSUMPTION. 79 

facreased action is sometimes left, which degenerates into 
chronic inflammation : nevertheless, this chronic is not al- 
ways the relict or the effect of an acute inflammation of the 
pleura, as it may arise slowly, without the least depend- 
ance on the latter 5 and though it generally proceeds with 
its proper characters, yet it is at times suddenly converted 
into an acute inflammation, from cold, great exertion, or 
some similar cause. When, however, chronic pleuritis is 
the relict of the acute, the subject of it does not gradually 
or suddenly recover his health, as is usual after depletion. 
On the contrary, he remains weak, and is short of breath 
in going up stairs, has a degree of slow fever at nights, feels 
some oppression in the chest on lying down, and his sleep* 
are generally short, and disturbed. The appetite is fre- 
quently bad, or at least very variable : in some cases the 
tongue is foul, but in others tolerably clean ; and the belly 
is commonly slow, and the urine scanty and high coloured. 
There is a short tickling cough throughout the day, which 
is commonly increased for a time on lying down, and often 
troublesome in the mornings. The patient is almost inva- 
riably easiest when sitting still upon the breech, with the 
trunk supported against a sofa or an easy chair 5 but ask 
him a succession of questions, or request him to walk across 
the room, and the chest will soon begin to heave, and the 
respiration will be perceived to be much hurried. Place 
even a healthy person beside him, and on counting the res- 
pirations of both, the number of his will be found the great- 
est in the minute. If he be requested to take a deep inspi- 
ration in the erect position, he can sometimes do it with 
little apparent uneasiness ; but lay him down flat, as Bagli- 
vi has advised, and, causing him to fetch his breath deeply, 
he will be almost certain to complain of pain^ tightness, 
soreness, load, or some species of inconvenience^n the 
chest. His pulse will often be tolerably calm in the morn- 
ing when he is perfectly quiescent ; but, corresponding in 
some measure to the respiration, it will be much accellera- 
ted by motion* Besides, there is generally a degree of 
soreness in the integuments of the side affected ; in some 
cases it is exceedingly slight, and in others it is distinctly 
felt at all times, especially on pressure. Occasionally I 
have known this sense of soreness, which arises from the 
sympathy between the pleura and the skin, diffused over a 



80 PULMONARY CONSUMPTION. 

considerable space, so that the patient felt as if he had been 
beaten by a rod, or as if the side had been bruised. But in 
the majority of examples, the soreness is limited to a partic- 
ular part, and it is often so obscure, as only to be experien- 
ced on strong fits of coughing in the supine posture. Now 
and then the chronic inflammation of the pleura is rather 
denoted by a sort of dragging feeling in the. side, always re- 
ferred to the same quarter, and always attended with more 
or less cough ; and the above feeling is especially liable to 
occur when the inflammation arises slowly of itself, inde- 
pendent of any acute disease. In such cases, an occasion- 
al stitch, or some uneasiness in the breast, and a short dry 
cough, generally mark the accession of the insidious inflam- 
mation ; but these are often taken for the mere symptoms 
of an ordinary cold, as they produce little disturbance in 
the general health at first, and as they seem to be in some de- 
gree under the influence of the weather. But as the dis- 
ease steals on, some shortness of the breath becomes ap- 
parent, the face upon the whole is paler than natural, the 
temper much more irritable, and the nights are uncomfort- 
able for want of the usual long and sound sleeps. If pro- 
perly examined, some pain, soreness, or heaviness, may still 
be detected in the right or left side, with a quickened pulse, 
and other evidences of an irregular fever ; and a greater 
desire for fresh air is expressed than formerly, but particu- 
larly at nights, the curtains of the bed being instinctively 
drawn open by patients, and the head raised with pillows. 
The disease now proceeds in a similar manner as when it 
follows an acute attack of inflammation ; and as it daily 
saps the foundations of life, under the fallacious covering 
of general debility, the cough, shortness of breathing, and 
fever become more troublesome, until at last dyspnoea and 
emaciation are the two most prominent symptoms. In- 
deed, towards the close of the disease, the breathlessness is 
most frequently extreme, but great temporary relief is some- 
times procured from the use of a swing, and that even 
where the motion does not induce sickness. The deat 
often sudden at last, and is almost always preceded by ana- 
sarca of the lower extremities. 

This affection is principally distinguishable in its earlier 
stages from the tubercular consumption, by the uneasiness 
in the side being confined within a certain space, by the 



PULMONARY CONSUMPTION. 81 

gradually increasing difficulty in the breathing, and by the 
common motion of the body aggravating, and by rest alle- 
viating the symptoms ; and in the last stages it is to be dis- 
criminated by the fever not observing the hectic character, 
and by the absence of pus in the expectoration, which 
throughout is usually scanty, and consists of vitiated mucus, 
when chrynic pleuritis is uncombined with inflammation of 
the lungs themselves. Where the measles have left a ten- 
dency to inflammation in the pleura, this affection is apt to 
follow them, if children be exposed to cold, or allowed too 
full a diet : but it is sometimes produced in adults, by the 
exhibition of diffusible stimuli or strong food during their 
convalescence from acute pleuritis; and sometimes it di- 
rectly, though slowly, arises from a blow upon the breast, 
or from an exposure to intemperate weather. Upon the 
whole, females have appeared to me more liable than males 
to chronic inflammation of the pleura ; and perhaps this is 
owing to the mode of dress adopted by the former, which is 
not only thinner, but which particularly exposes part of the 
chest. It would perhaps be difficult to find any enlighten- 
ed country where the dress of the females is less suited to 
the climate, and to the social customs, than in England : 
and it is a national opprobrium, that the lives of many moth- 
ers and daughters should continue to be yearly lost, from 
the prevalence of false taste and injudicious fashions. 

Chronic inflammation of the lungs themselves is not un- 
frequently the concomitant or the result of the preceding 
disease. Accordingly I have seen, in morbid dissections, 
the pleura considerably thickened, with an effusion of se- 
rum and of some coagulable lymph in the chest, and a por- 
tion of the lungs, which had apparently been impervious 
to the air, converted into a solid and compact substance, 
not much unlike that of the liver ; and whenever this 
change of structure is effected by inflammation in a partic- 
ular part, it throws the work of respiration in a proportion- 
al degree on the sound portion of lung, and it is sometimes, 
I suspect, a cause of haemoptoe by obstructing the pulmo- 
nary circulation. Again, in some other instances I have 
met with superficial abscesses in. the lungs, immediately 
under that part of the pleura pulmonis which had been in- 
flamed. In a case of this kind, which came under my care 
last year, the patient was afflicted with chronic inflamma- 

11* 



m PULMONARY CONSUMPTION. 

tion of the pleura for nearly twelve months : and he never 
expectorated any pus, until a few weeks before his death, 
and then only in small quantities. On examining the body, 
no tubercles were found in the lungs, but a common im- 
posthume existed under a portion of the pleura, which 
bore strong marks of a previous inflammation ; and there 
was some water in the thorax, with shreds of coagulable 
lymph floating in it, and a thick layer of the same substance 
over the surface of the right lung. Chronic pleuritis most 
frequently terminates by hydrothorax, which, together with 
the febrile irritation, wears out the strength at last. But 
when inflammation of the lungs is present at the same 
time, and when that inflammation ends in an abscess, the 
disease is of shorter duration, and then it very strongly re- 
sembles the genuine phthisis in the last stage, the forma- 
tion of matter converting an irregular fever of irritation 
into the hectic. In examples of this nature, the inflamma- 
tion of the lungs is for the most part simply an extension 
of the increased action, originally seated in some part of 
that reflection of the pleura, by which they are immediate- 
ly invested; and even where the chronic inflammation 
commences in the body of the lungs themselves, I am not 
aware that a nosological distinction can be of any practical 
use, when the inflammation is of the same nature as that 
which attacks the pleura. Yet as chronic inflammation 
of the body of the lungs does occur independently either 
of chronic inflammation in the pleura, or of chronic in- 
flammation in the bronchia, it may not be amiss to say a 
few words on the subject, by way of exciting inquiry. 

The abscess which follows acute inflammation of the 
lungs is attended with a distinct and impressive concourse 
of symptoms ; whereas that resulting from a chronic and 
simple inflammation takes place without many of what are 
deemed the diagnostic signs of such an event. On the ex- 
amination of the bodies in two cases, where suppuration of 
the lungs had not been suspected till a short time before 
death, an extensive abscess was found in the left lung of 
one, and two small ones in the right of the other. Both 
these cases had been ushered in by a lassitude, without any 
strongly marked symptoms of pulmonary disorder. About 
two or three weeks from their commencement, the disease 
in both put on the character of an irregular ague ; for cold. 



PULMONARY CONSUMPTION. 83 

hot, arid sweating stages returned at intervals for more than 
a month, and these were succeeded at last by a confirmed 
hectic. The appetite remained tolerably good in both ca- 
ses, and the sleep for some time was often long and sound, and 
the respiration, upon the whole, far less disturbed than 
might have been expected. In another example, in which 
the fever from the first to the last observed the remittent 
form, suppuration had taken place in the liver as well as 
in the lungs ; and yet the symptoms were such as to make 
me suspect that the chief seat of the disease was in the 
glands of the mesentery, which were found quite natural. 
These cases are surely sufficient to put practitioners on 
their guard in respect to those fevers assuming the inter- 
mittent or remittent features : as such fevers may occasion- 
ally arise from the formation of matter about some of the 
vital viscera, but more especially about the lungs and the 
liver. Some facts have occurred which would incline me 
to believe, that the chronic inflammation of the lungs, and 
a consequent abscess may occasionally arise from coagula 
of blood retained after an haemoptoe ; and I knew one in- 
stance which dissection showed to have arisen from a de- 
position of calcareous matter, which had probably been 
secreted from the bronchia. Yet I cannot help remarking, 
by the way, that my own inquiries lead me to infer, that 
calculi formed in the pulmonary system are generally not 
so dangerous as Morgagni supposed, who concludes, from 
an elaborate account of them, that they are oftener danger- 
ous than the contrary ; whereas from my own experience, 
and from that of some friends, a directly opposite inference 
might be drawn. But this is a point which could only be 
settled by an extensive collection of facts. It is a little re- 
markable, that in three cases where small calculi were ex- 
pectorated, the digestive organs seemed disordered, indica- 
tions of very great acidity existing in the primae viae. All 
these patients had a short, tickling,troublesome cough,which 
in two were apparently much relieved by the use of mag- 
nesia 5 and in the third, in whom the hepatic secretions were 
vitiated, it yielded rapidly to small doses of calomel, and 
an occasional dose of an infusion of colomba, with the 
corbonate of potass. From a review of these three cases, 
might it not appear, that the secretion of calcareous mat- 
ter in the lungs, or from the bronchia, is connected with 



84 PULMONARY CONSUMPTION. 

disturbance in the digestive functions ? And does not this 
suggestion derive some support from the known fact, that 
the deposition of calcareous matter in other parts of the 
body is often seen in conjunction with some disorder of the 
stomach, liver, or intestines ? Finally, however, to advert 
to the original topic, I know of no symptoms which can en- 
able us to say when chronic inflammation of the lungs is, 
and when it is not, connected with chronic inflammation 
of the pleura ; and if we possessed any facts enabling us to 
determine this point, still they would be of little practical 
utility, since the treatment must be similar, whether simple 
or combined. Such obscurity, indeed, hangs over the form- 
ation of that species of chronic inflammation of the lungs, 
which occurs independent of any similar affection of the 
pleura or bronchia, that I readily confess myself unable to 
enumerate any signs by which it may be certainly distin- 
guished ; although a minute investigation into the histories 
of the few cases which fell immediately under my inspec- 
tion fully proved, that a slight degree of fever, an occasion- 
al cough, with a deep yet very indistinct feeling of uneasi- 
ness within the chest, had existed from the beginning. And 
whenever we observe such systems, we ought to be most cir- 
cumspect in our conduct, because they may lead to a com- 
mon abscess in an ordinary habit, or they may be connected 
with tubercles in a phthisical one. 

In his valuable work on consumption, Dr. Duncan, senior, 
has prepared the way for more correct and comprehensive 
views on the formation of pus in the lungs, by considering 
it the result of catarrh, as well as of acute inflammation, 
and of tubercles ; whilst Dr. Philip, in an able tract, has 
decidedly fixed the attention of the medical public on the 
important connection between hepatic and pulmonary dis- 
order. Still there is need of accurate histories and ar- 
rangements of some chronic affections which resemble 
phthisis. It is evident, that under the term phthisis, disea- 
ses very different in kind have been comprehended ; and 
it would obviously lead to improve the treatment of those 
diseases were their respective causes and nature clearly as- 
certained and defined. This is so far from having been ef- 
fected, that even among our most useful writers we find very 
indefinite ideas on the subject ; and of how little value are 
the few remarks above respecting it I am fully sensible, 



PULMONARY CONSUMPTION. 85 

but hope that they will excite practitioners to remove what 
is obscure, and to supply what is defective. Besides those 
already considered, there are disorders of the heart, and 
of other parts, which sometimes appear like phthisis ; my 
experience, however, has not yet enabled me to speak with 
sufficient precision of the former, and ta the latter some 
allusion shall be made in the sequel. 

When the first edition of this work passed through the 
press, I had not seen the treatise of M. Bayle, whose ar- 
rangement, in some respects, resembles that which I had 
adopted from my own observation, though his, upon the 
% whole, will be found much more complicated. So far as 
the pathological anatomy of phthisis is concerned, M. Bay- 
le appears to me to have surpassed every author who has 
written upon the subject, in the minuteneness and number 
of his inquiries ; and the philosophical simplicity and can- 
dour with which he has delivered his statements, become 
deeply affecting, when one considers, that this estimable 
man himself fell a victim to the tubercular phthisis, the in- 
curable nature of which he was earnest to establish. Some 
of the distinctions, however, of M. Bayle, are not of any 
practical utility 5 and it is to be regretted, in a work so tru- 
ly valuable, that more attention had not been paid to the 
history and diagnosis of those affections which resemble the 
genuine consumption. 

According to my observations, the true tubercular phthis- 
is only occurs in habits of the strumous temperament; and 
it yet remains to be proved, whether tubercles be ever 
formed in the lungs, without an hereditary predisposition to 
them. Generally speaking, the strumous temperament ap- 
pears under two modifications, which require to be discri- 
minated. The first of these is found in those who natural- 
ly have pale skins, loose, flabby fibres, and a sluggish pulse : 
and the second, in those who have ruddy complexions, 
firmer fibres, and a brisk circulation. Subjects of the first 
modification have seldom much corporeal vigour or mental 
vivacity, whereas those of the second often possess both. 
But there is one thing common to these two modifications 
— an unusual irritability of the capillary arteries ; an irri- 
tability which is perhaps one of the most essential peculi- 
arities of the strumous temperament. The actual seat and 
developement of scrofula may partly depend upon this irri- 



86 PULMONARY CONSUMPTION, 

lability being more abundant, from their construction, in 
some organs than in others, and partly upon the force of 
morbid impressions being mainly directed to those organs ; 
hence, in one patient the membranes or ligaments investing 
the bones will be attacked, in a second the glands of the skin, 
in a third the mesentery, and in a fourth the lungs, accord- 
ing to the state of each organ, and to the nature of the ex- 
citing cause. Now the predisposition to the genuine phthis- 
is, I suspect, chiefly consists in an unusual irritability in the 
capillary arteries in the cellular connecting membranes of 
the lungs; and wherever this predisposition exists, any 
cause agitating or stimulating the lungs may lead to tuber- m 
cles, and of consequence to phthisis ; but where this pre- 
disposition is absent, it is probable that no such cause can 
ever excite, much less produce the disease in question. The 
tubercles themselves are, perhaps, formed by exudations 
from the minute vessels in the cellular tissue of the lungs ; 
and these exudations, though becoming partially organized, 
may be considered as almost extraneous substances at last, 
from the interruptions which they give to the pulmonary 
circulation, and from the local irritation which they induce.* 
On examining the bodies of young children, I have some- 
times found tubercles or the germs of tubercles in the lungs, 
where no signs of pectoral disease had previously existed : 
and I have met with them likewise in adult lungs, where 
there had been no sufficient grounds for suspecting them 
during life. Such occurrences have led me to suppose that 
tubercles may sometimes be congenital, and that at other 
times they are the slow and unsuspected products of later 
periods. In many cases, tubercles of the lungs remain long 
latent, before the evidences of disease become strikingly 
manifest ; and what is frequently supposed the commence- 
ment of phthisis, is but some local or constitutional irrita- 
tion exciting previously formed tubercles into inflammation 
or suppuration. But as the causes which thus excite tuber- 
cles already formed, are also most likely to produce them in 
the phthisical habit, it is doubly needful to be acquainted 
with those causes : first, that the formation of tubercles may 

* Broussais, an ingenious French writer, supposes that what we 
call tubercles are merely the lymphatic glands of the lungs, diseased 
and enlarged by some adjacent irritation, in the same way as happens 
in other parts of the body, and in many other diseases. 



PULMONARY CONSUMPTION. 

be warded off in suspected constitutions ; and secondly, 
that their excitement may be prevented where they really 
exist. The causes of this kind, are, local irritations within 
or without the chest, certain morbid states of the skin, 
and those circumstances which act generally by breaking up 
the strength of the system. Unless, however, the true 
phthisical tendency co-operate, these causes will not excite 
the tubercular composition. As if to guard the body or the 
lungs against disease of irritation, nature has generally made 
them but little sensible ; and it is only perhaps in peculiar 
exceptions from this structure that such affections invade 
their substance. 

That chronic inflammation of the bronchia, of the tra- 
chea, of the pleura, and of the lungs, are not essential to the 
tubercular phthisis, we have sufficient proof, in their exist- 
ing without that distemper, and that distemper without 
them ; and in speaking of them, and of other local and more 
distant irritations, we must still return to this pathological 
principle, that they merely become exciting causes of genu- 
ine phthisis, in subjects whose lungs are predisposed to it 
from original organization. The preceding affections of the 
chest are very common, as we are surrounded by the occa- 
sions which call them into existence : the hereditary ten- 
dency, also, to phthisis is so common in this country, that 
there are perhaps few families where it is not found ; and 
hence these affections, favoured by this predisposition, so 
often become the excitants of this wasteful malady. When 
such affections occur, therefore, the sooner they are remo- 
ved, the better, since they are not only dangerous in them- 
selves, when uncombined with any other disease, but since 
their removal may prevent an attack of phthisis itself. Pre- 
cisely the same mode of reasoning may be applied to cer- 
tain disorders of the stomach, liver, spleen, bowels, and 
urethra ; for each of these may become an exciting cause of 
phthisis in particular constitutions, though in ordinary ones 
they take place separately and independently. Sir Richard 
Blackmore divides pulmonary consumption into the original 
and the secondary. The original, to use his own language, 
is that consumption the seeds of which are either compli- 
cated with the stamina vitae, or afterwards formed in a de- 
generate and depraved blood : the secondary is that con- 
sumption induced by peripneumonies, measles, malignant 



88 PULMONARY CONSUMPTION. 

fevers, hypochondriasis, jaundice, lues venerea, fistulas, ul- 
cers in the guts, and various other diseases which, as he fig- 
uratively remarks, end in tabes of the lungs, as numerous 
streams run into some ample river, and lose their denomi- 
nation.* In the second book of his work relative to the 
seats and causes of diseases, Morgagni shows, that the cau- 
ses of affections of the lungs may not only exist in the tho- 
rax, but in the neck, in the head, and in the belly ; and 
he commends Galen for having expressly taught, that 
certain disorders of the stomach, liver, and spleen, dis- 
turb the organs of respiration. Moreover, he observes, 
that in other complants, as well as in those of the chest, 
the cause which really belongs to the belly, is often 
wrongfully ascribed to the thorax, on account of practi- 
tioners not knowing or not considering the height to which 
the upper cavity of the abdomen and its superior viscera 
penetrate within the diaphragm. Indeed, in different pla- 
ces, he lays considerable stress upon the connexion between 
the liver and lungs, and has given some dissections in which 
both were found in a morbid state : yet he has not carried 
the doctrine so far, nor illustrated it so well, as some more 
recent writers of our own country ; and too much praise 
cannot be given to Mr. Abernethy, and to Dr. Philip; for 
the lights which they have thrown, from opposite points, on 
this interesting subject. Morton, the rival of Sydenham, 
dedicated a whole chapter, in his elaborate treatise, to what 
he calls the hepatic consumption ; and though it contains 
much of crude speculation, yet it shows that he was not al- 
together unacquainted with the intimate association which 
often exists between the liver and the lungs. 1 In a proper 
habit, phthisis is more liable to be excited by affections of 
the liver, than of any other adjacent viscus, but it sometimes 
supervenes an enlarged spleen, obstructions of the mesen- 
teric glands, and irritation in and about the rectum. Dis- 
orders of the liver and spleen may in some measure act me- 

* A Treatise of Consumption and other Distempers belonging to the 
Breast and Lungs. By Sir Richard Blackmore, Kt. M. D. and Fel- 
low of the Royal College of Physicians in London. See p. 39, 40. 48. 
London : printed for John Pemberton. 1 724. 

•(■ See p. 307 of Phthisiologia : or a Treatise of Consumption. By- 
Richard Morton, M. D. Translated from the Original. The Second 
Edition corrected. London : printed for W. and J« Innys. mdccxx. 



PULMONARY CONSUMPTION. 89 

ohanieally, by irritating the lungs from their pressure a- 
gainst the diaphragm ; yet as this cannot be said of the 
other textures specified, we must look to some other cause 
to explain their influence upon a distant organ. One local 
disease may produce another by causing a general irritation 
in the nervous system, an irritation which re-acts upon and 
excites the whole vascular system ; and the latter, in its 
turn, operates morbidly and manifestly upon some part 
where a previous, though a latent fault had existed. It is 
upon this principle, that an external injury or operation is 
sometimes followed by symptoms of visceral disease ; so 
that in one patient the brain shall be excited, in a second 
the lungs, in a third the liver, and in a fourth the intestines. 
It is on this principle, too, that tubercles may be roused into 
action, or perhaps actually produced in the true phthisical 
habit from a remote irritation ; for whether that irritation 
be external or internal, it may, through the nervous opera- 
ting on the vascular system, so increase the action of the 
capillary vessels in the lungs, as at once to prove a princi- 
pal cause of this disease. In some patients predisposed to 
phthisis, I have seen a short tickling cough arise and disap- 
pear with the primary symptoms of syphilis ; but in others, 
who had exposed themselves to cold, or who had taken mer- 
cury injudiciously, I have known the cough advance until 
suppuration of the lungs took place. Again, in constitu- 
tions of a similar cast, 1 have witnessed a train of dyspeptic 
symptoms from a stricture of the urethra, and these at last 
were succeeded by tabes of the lungs. From the consider- 
ation of such facts, therefore, we cannot be too careful in 
speedily removing any irritation from a phthisical habit ; 
for even if that irritation should not at first be dangerous in 
itself, it may in the end become highly so, by implicating 
the pulmonary organs in disease. But before concluding 
this part of the subject, I cannot refrain from remarking, 
that there is something peculiar and insidious in the nature 
and effects of strictures of the urethra. They are some- 
times the unsuspected causes of gleets, of ulcers on the 
penis, of enlargement of the testes, of febrile paroxysms, 
and of abdominal and thoracic complaints. A patient may 
have a stricture for years without suspecting it ; yet during 
this period he shall be liable to some of the affections just 
mentioned, which can hardly ever be cured without remo- 

12* 



90 PULMONARY CONSUMPTION. 

ving the original cause by the introduction of bougies. In- 
particular, sometimes an intimate sympathy exists between 
the mucous membrane of the urethra, and the same tissue of 
the intestines and of the bronchia ; so that I have met with 
instances of a chronic disorder in the mucous membrane of 
the urethra, which were followed by morbid secretions of the 
bowels and bronchia ; and the disease has at last assumed 
the character of chronic inflammation of the bronchia, with 
purulent expectoration. Many parts of the body sympa- 
thize with the urethra, and the urethra in like manner with 
them ; and notwithstanding the valuable facts which are to 
be found in various works, we still want a concentrated il- 
lustration of this curious subject. 

Certain conditions of the skin are more frequently con- 
nected with the rise and progress of phthisis than perhaps 
any of the above noticed irritations ; and it is to this organ 
unquestionably, that we must often look for the commence- 
ment of those morbid movements which ultimately under- 
mine the fabric of the lungs. We cannot put a needle into 
any point of the skin without drawing blood and exciting 
pain, which demonstrates it to be an extremely vascular and 
nervous tissue. In fact, we may consider it as an expansion 
of larger or minuter vessels and nerves, so completely are 
they interwoven with every fibre of its substance. From 
such an union of two distinguished textures, one might nat- 
urally suppose the skin a most important organ ; as physiol- 
ogy has shown, that to those parts, the most highly and per- 
fectly organized, the most important offices of the economy- 
are committed. The whole extent of the skin is perpetu- 
ally exposed to the action of surrounding agents, and be- 
tween it and the central parts an intimate sympathy exists, 
but especially between it and the lungs : for not only do the 
skin and the lungs mutually compensate a deficiency or an 
excess in their respective exhalations, but they are likewise 
closely connected by a free intercourse of vessels ; so that 
when a reduced temperature diminishes the action of the 
skin, it at once increases that of the lungs, and the contrac- 
tion of the vessels on the former in some degree congest 
those of the latter. Where is pulmonary consumption un- 
known, and where does it abound ? Is it not unknown in 
most of the warm and temperate, and does it not abound in 



PULMONARY CONSUMPTION. 91 

most, if not in all of the cold and variable climates ? In 
good warm climates the action of the skin is constantly ex- 
cited, and that of the lungs is proportionally diminished ; 
and on this account we there find diseases of the surface very 
common, those of the lungs comparatively rare. In cold 
and variable climates, on the contrary, the action of the skin 
is diminished, that of the lungs of course augmented in a di- 
rect ratio ; and therefore in them this increase of labour 
renders the latter organ much more susceptible of disorder 
than the former ; as it is a pathological law, that the more 
any part is exercised, the more apt it is to be diseased, — 
What are the remedies, generally speaking, which we find 
most efficacious in warding off the threafenings of genuine 
phthisis ? Are they not chiefly those which act upon the 
skin, as blisters, emetics, a regulated temperature, and more 
especially a change to a warm climate ? Who are the 
persons most liable to tubercular phthisis ? Those who 
have delicate skins and who are exposed, without sufficient 
clothing, to the vicissitudes of the weather. Nay, if we go 
more minutely into this subject we shall find, that many 
diseases of the skin are incompatible with those of the lungs \ 
that is to say, certain excitements of the first organ often 
prevent dangerous affections of the last. Hence it is, even 
in Great Britain, that those persons afflicted with cutaneous 
diseases are the least obnoxious to pulmonary consumption ; 
but let their cutaneous diseases be incautiously cured, and 
they often afterwards fall victims to suppuration in the 
lungs, as I well know from personal observation. Besides, 
in some instances, I have seen coughs of a phthisical ten- 
dency disappear on the coming out of a spontaneous erup- 
tion of the skin ; and I have occasionally seen a similar ef- 
fect from pimples artificially induced on the surface by an 
irritating unguent. Phthisis, too, is so apt to supervene 
those fevers which are attended with affections of the skin, 
that too much care cannot be paid to patients in a state of 
convalescence ; for if they should be incautiously exposed 
to a cold or variable atmosphere before they may have ac- 
quired their full vigour, they will be very liable to lapse into 
pulmonary consumption. Whatever might be their specu- 
lative notions, the ancients certainly paid far more regard 
than the moderns to the skin in pulmonary complaints. We 



92 PULMONARY CONSUMPTION 

accordingly find, that Celsus recommends several ulcers* 
to be made in phthisis, and directs the employment of fric- 
tions ; whilst iEtius, carrying the practice still further, al- 
most covered the skin with issues, both in that disease and in 
asthma. t Similar methods of treatment seem to have pre- 
vailed for centuries, and only fell into disrepute on the de- 
cline of the humoral pathology ; as in the ceaseless changes 
of human opinions many estimable things have been undis- 
tinguishingly condemned, with the absurdities upon which 
they had been accidentally established. The connection, 
through the medium of nerves and of blood-vessels, between 
phthisis and the skin, appears to me a subject of vast im- 
portance in a pathological and practical view ; and I could 
earnestly entreat practitioners to investigate it narrowly, as 
they value the vital interests of society, and the advance- 
ment of the medical art. An immense majority of patients 
attribute the origin of phthisis to cold, and can recount the 
circumstances under which they were exposed to its influ- 
ence. If we accurately trace the history of such cases back- 
wards, we shall invariably find, that the functions of the skin 
were first disordered, and that they continued more or less so 
during the whole attack ; the surface being at first chilly, 
with a diminished perspiration, and afterwards chilly and 
hot alternately, with irregular returns of dampness and 
of dryness. Nay, what are the colliquative sweats in a con- 
firmed phthisis but an increased action of the skin to com* 
pensate the interrupted functions of the wasted lungs ? For 
a certain portion of carbonic acid gas, and probably of other 
fluids, is to be thrown out of the system, and as the lungs 
cannot then completely perform their w r onted share of the 
work, they are assisted in their office by the skin. It were 
needless to tell us, that these sweats exhaust the strength 
of the patient, for it is readily admitted that they do ; but 
they constitute the best natural mean of removing an imme- 

* Exuteerandus est ferro candenti, uno loco sub mento, altero in gut- 
ture, duobus ad mammam utramque ; item sub imis ossibus scapular- 
um, sic, ne sanescere ulcera sinamus, nisi tussi finita cui per se quoque 
medendum esse, manifestum est. A. Corn. Celsus de Re Medica, pj 
124. Glasguae : excudebat Gulielmus Bell, mdcclxvi. 

j The reader will find an interesting account of the practice of Mti- 
us in The History of Physick, from the Time o r Galen to the beginning 
of the Sixteenth Century. By J. Friend, M. D. The fourth Edition. 
Vol. i. p. 36, 37, 38. London : printed for M. Cowper. m.d.ccl. 



PULMONARY CONSUMPTION, 93 

diate evil — the excessive accumulation of noxious and ex> 
crementitious matters in the body. This is not merely a 
speculative opinion ; it may be proved by the test of ex- 
periment. If, by any measure, the colliquative sweats be 
checked in the last stage of phthisis, the lungs invariably 
become more oppressed, because a labour is thereby 
thrown upon them, to which they are incompetent. Nor 
does the consequence end here ; for if the lungs be not re- 
lieved by a copious flow of urine, a colliquative diarrhoea is 
produced, and the patient may sink with rapidity, if the 
sweats should not be restored. The colliquative sweats in 
the last stage of pulmonary consumption can only be mode- 
rated with safety, by exciting a flow of urine ; for the kid- 
neys form a sort of intermediate apparatus between the 
lungs and the skin, and on certain emergencies partly or 
wholly compensate, by various changes of action, any dis- 
turbance in the operations of either of the latter. Hence, 
most affections of the chest are alleviated by a free secretion 
of urine, — a fact conspicuously noticed by Baglivi ; and 
hence, also, when the action of the skin is diminished, that 
of the kidneys is increased, otherwise the lungs would be far 
more liable to congestions of blood, especially in our cold 
and variable climate. 

If then the skin, as is indisputably the case, be very of- 
ten concerned, intimately concerned, in the pathology of 
phthisis, it obviously follows, that upon this principle pre- 
ventive measures might be adopted. The sailors, who 
trade along the northern coasts of England, might at first 
sight appear to be liable to attacks of phthisis at sea, as 
they are so much exposed there to the severities of the 
weather ; and yet I have hardly ever been able to trace 
the origin of this distemper, in such subjects, to the effect 
of cold when they were actually at sea. This power of re- 
sisting the exciting causes of pulmonary consumption in so 
peculiar a situation, I am inclined chiefly to attribute to the 
flannels with which those men cover the surface, and to the 
woollen dresses which they wear when on ship-board : and 
this opinion has been the more strongly impressed upon me, 
by having ascertained that when they do actually become 
consumptive, the attack may almost always be traced to an 
imprudent disuse of their flannels while on shore, together 
with the influence of dissipated habits. But it ought to be 



94 PULMONARY CONSUMPTION. 

observed, that though the dress of sailors be warm, it is also 
composed of such light materials as not to fatigue or ex- 
haust them by its weight, or by its increasing the perspira- 
tion too much ; and I am convinced, that many persons 
waste their flesh as well as their strength by wearing too 
great a quantity of clothing. It is well known to grooms, 
that the fulness of any part of a horse may be reduced ra- 
pidly by continuing to cover it with many folds of woollen ; 
and what here takes place in a particular part, may also be 
induced in every muscular part by similar means, even in 
the human body. It is, therefore, of great consequence, as 
a preservative of the health, to make the clothing light as 
well as warm ; since its principal utility consists in preserv- 
ing an uniformity of the animal heat in all parts of the sys- 
tem. If any practitioner attend to those phthisical cases 
which fall under his immediate inspection, he will find, that 
most of them exist in patients who had been careless about 
their clothing : if he extend his observations still further, he 
will be satisfied, that many persons, having a constitutional 
tendency to this disease, attribute their exemption from at- 
tacks of it to the constant use of a general covering of flan- 
nel or of worsted hosiery; and a minute inquiry into the 
history of these cases will generally confirm the conviction, 
which has thus resulted from an experience of their own 
feelings. Some hints were thrown out, in a former page, 
respecting the insufficient protection which the dress of fe- 
males affords to the surface ; and it may also be observed, 
that even the common dress of men is not an adequate se- 
curity, where there is the least tendency to any thing like 
phthisis. In short, in such a changeable climate as ours, 
every body should wear flannel or fleecy hosiery next the 
skin ; and persons of the higher class should be mindful to 
make their evening correspond to their morning dress, in 
point of warmth. By covering the skin with those substan- 
ces which are bad conductors of caloric, we in some mea- 
sure preserve an equilibrium of temperature between the 
centre and the surface, which tends much to preserve the 
health : but this expedient has a special power over the 
lungs, for the skin is thereby constantly stimulated, and of 
consequence the respiratory organs, as before explained, 
have a less share of work, and are rendered less liable to 
morbid accumulations of blood. In autumn, winter, and 



PULMONARY CONSUMPTION. §b 

spring, the greatest care should be taken as to clothing, the 
atmosphere being then most chilly and changeable. Yet 
even in summer, the lighter flannel or worsted hosiery should 
generally be worn, more especially by the delicate ; for 
even at that season we often have a considerable range of 
the thermometer in the course of the day, by which we are 
apt to be chilled after having been heated, if we wear linen 
next the surface. There are, however, some irritable per- 
sons who cannot wear flannel next the skin, from the uneasi- 
ness which it excites ; and in such, thin wash leather will be 
found a most excellent substitute, as it warms without irri- 
tating the skin. Indeed I have known several patients, es- 
pecially females, give the decided preference to the leather, 
believing that it kept the heat of the surface more uniform 
than flannel. In North America, leather has long been 
worn next the skin by the natives, in their worst weather ; 
and to those who, from the comparative luxury of clean lin- 
en, dislike any thing under the form of flannel, it is a mate- 
rial from which they may derive considerable advantage, 
and at the same time possess all the comforts of cleanliness, 
by having it repeatedly washed. An intelligent friend re- 
cently informed me, that a body of manufacturers of glass 
had become much less liable to colds and coughs since 
they had worn flannel shirts at their work ; and as they are 
exposed to a considerable heat while employed on the glass, 
and as they cool themselves by standing in currents of air, 
their situation is somewhat analogous to our own in sum- 
mer, since we are heated and cooled in the same day. So 
repeatedly have I seen the advantages of the mode of cloth- 
ing here recommended, that I could wish it were universal- 
ly adopted in this country, but particularly by females, 
whose natural delicacy renders them less competent to re- 
sist the vicissitudes of the atmosphere. 

The dress of females in particular is an inadequate secu- 
rity against the weather at all seasons, but especially in the 
winter and spring ; since it is not only far too thin in the 
mornings, when the arms, breast, and neck, are covered, but 
it is still more so in the evenings, when the neck is entirely, 
and the arms and breast partly exposed. It is surely s 
great defect in education, that young women should be 
taught such an unceasing regard to the decoration of their 
persons, and to the extreme polish of the mere exterior; 



96 PULMONARY CONSUMPTION. 

for by an adherence to this system, simplicity of manner, 
sincerity of mind, and even health, are often wholly sacri- 
ficed. Most females should wear a chemise and drawers^ 
of light flannel, with warmer stockings and stronger shoes 
than are worn at present. Between the feet and the rest of 
the surface there is a surprising sympathy, so that if the 
former be cold, the whole skin is apt to be affected as to 
temperature-, and hence may be explained, from the ner- 
vous and vascular consent between the skin and the lungs, 
the known frequency of coughs from coldness of the feet. 
In wet seasons, both delicate men and women should wear 
leather clogs over their shoes, as they are exceedingly use- 
ful in keeping their feet dry and warm. By the adoption 
of this simple expedient, I have known some persons escape 
coughs, who had previously been liable to them from hav- 
ing had their feet chilled through their shoes in damp weath- 
er. If females wore flannel, and if the neck, the arms, and 
breast were always covered, they would be much less sub- 
ject to phthisical, congestive, and inflammatory complaints. 
Though I practised much among the Society of Friends 
while at Sunderland, it is remarkable, that I only attended 
one young woman of their denomination who died of pure 
consumption ; and as the disease was not uncommon among 
other young women of that place, the greater exemption of 
those of the Friends appeared to depend chiefly upon their 
dress, that has a simplicity and protection which it would 
be well for others to imitate. Indeed many of the habits of 
this respectable Society are highly conducive to health. 

The universal use of linen in modern times has largely 
contributed to promote personal cleanliness, and to gratify 
those feelings of animal pleasure which are connected with 
cleanliness. This observation, however, is only applicable 
to the higher and middle orders of society, for among the 
lower linen is generally worn until it be covered with dirt ; 
though it is much to be regretted, that in many large towns, 
but especially in London, the poor, who live so much hud- 
dled together, are by no means sufficiently well supplied 
with water for the purposes of washing their houses and 
clothes. If among the labouring classes linen shirts were 
laid aside, and flannel ones substituted, a great improve- 
ment might be effected in cleanliness and health ; for as the 
latter are cheaper, they might be more frequently changed. 



PULMONARY CONSUMPTION. 97 

and the men, by resisting cold better, would not be so sub- 
ject to those chills which follow hard labour when linen is 
worn next the surface. The human system has an exten- 
sive power of accommodating itself to surrounding circum- 
stances, and particularly to the changes of the atmosphere. 
But the climate of Great Britain, which constitutes its bad- 
ness, is so exceedingly variable, that even the pliancy of 
this power cannot preserve us from its influence ; and to 
defend the surface as much as possible from the shocks of 
atmospheric variations, is one of the best means of preserv- 
ing the centre sound, where life may be said more immedi- 
ately to reside. When the clothing has once been made 
suitable, so far from advising persons in general to shun the 
vicissitudes of the weather, I would advise them to expose 
themselves, that they may be strengthened from the force of 
habit against surrounding circumstances. It were indeed 
foliy, on most occasions, to shrink from an encounter with 
those things which our situation has rendered in some mea- 
sure inevitable, but it is always better to meet them with 
every possible advantage on our side : and although the 
most fearless would not be so weak as to reject the use of 
weapons to parry an immediate attack upon life, yet many 
sacrifice that life through a neglect of the common precau- 
tions which our climate requires. People who follow se- 
dentary employments within doors are most liable to be af- 
fected by the weather when they go abroad ; and those on 
the contrary are the least liable to be affected by it who 
work in the open air, if they be properly clothed. The 
stronger persons are, the more successfully can they resist 
the changes of the atmosphere : but even the safety of them 
would be increased in the main by protecting the skin with 
some bad conductor of caloric ; and as for the weak of both 
sexes, they are exposed to perpetual perils without such an 
additional covering. From the dress of the ancient Bri- 
tons, from the high praises which the Romans bestowed up- 
on the temperature and soil of our climate, which they con- 
sidered alike adapted for vines or corn,* one would ima- 
gine that the seasons have undergone some remarkable al- 

* See some curious references to Eumenius on this subject, in voL 
i. p. 357, of The History of the Decline and Fall of the Roman Empire. 
By Edward Gibbon, Esq. of Dublin : printed for Luke White, No. 86, 
Dame-Street, 1789, 

13* 



98 PULMONARY CONSUMPTION. 

teration ; and even some old agriculturists, with whom I- 
have conversed, seem quite certain, that our climate has be- 
come considerably colder within their memory. A late in- 
genious writer appeared to be confident, that this was the 
fact, and attempted to account for it by an accumulation of 
ice in the north seas ; but whatever influence this may have 
had, it is highly probable, that the changes induced upon 
the surface of Europe, through the progress of agriculture, 
may have affected our climate as well as others ; though 
perhaps we shall never be able satisfactorily to account 
for the changes in the weather, until we shall be possessed 
of a more correct theory of the winds. This alteration of 
climate is an interesting subject of inquiry, and merits more 
attention than it has hitherto received from philosophers : 
but at all events, the present states of the seasons should 
claim the special notice of every medical writer!, as they 
are connected with many of our most dangerous diseases, 
and with none more intimately than phthisis. From the 
little regard which many medical writers seem to pay to 
the skin, one might almost suppose that they considered it 
an insensible envelope, somewhat like the outer bark of a 
tree : but 1 must again repeat, that it is an organ of vast im- 
portance, hardly any morbid phenomena occurring in which 
its functions do not more or less participate ; and this is 
the case, not only in the human, but in the brute economy, 
as any one may satisfy himself by marking the diseases of 
man, and of the lower animals. 

For some years past, I have observed how boys naturally 
delicate often improve in health and strength, by following 
some laborious occupation in the open air. But this fa- 
vourable change has been most apparent in some brought 
up as shipcarpenters, whose work is by no means light ; and 
I have been informed by an extensive ship-builder, that 
most of his apprentices, who had been previously weak, 
greatly improve in strength from their employment, provi- 
ded they be not worked too hard. " From these circum- 
stances it might be reasonably imagined, that those children 
or young persons who show much delicacy of constitution 
might be rendered much more robust by a regular training 
in some corporeal exercise ; and by this means become far 
less prone to those diseases which arise out of general de- 
bility, or which are connected with an incompetency, of 



PULMONARY CONSUMPTION. 9S 

the natural powers to repel the impressions of our trying 
atmosphere. The long neck, the narrow chest, with fee- 
bleness of muscular fibre, have generally been considered 
as the signs of hereditary predisposition towards phthisis ; 
and certainly wherever they exist, more than ordinary care 
ought to be taken, though I have occasionally seen con- 
sumption seated in chests of almost every form. It is an 
exceedingly rare circumstance to see negroes with narrow 
chests ; and it may also be remarked how very erect they 
are in their gait. They carry almost every thing upon 
their heads which Europeans carry in their hands, and this 
tends to make their gait erect, and to expand the chest ; for 
we see a similar effect produced among those women in the 
north of England who carry fish about for sale on their 
heads ; yet, as Camper asserts, the head of the African 
perhaps naturally inclines more backward than that of the 
European, which would effect both the chest and the gait. 
Probably, however, some plan of placing weights upon the 
head might be advantageous to children who have contrac- 
ted chests. But still exercise in the open air, and even 
some tolerably laborious employment, should mostly be 
considered as indispensable for children constitutionally 
weak ; because, if they be pent up at home, and especially 
if the free ventilation of the rooms where they sit be neg- 
lected, they are almost certain to become more or less 
chicken-breasted, and may at last fall into consumption, or 
some other strumous disease. From the observance of 
hardy exercises in the open air, the ancient Greeks became 
as much superior to the rest of the world in physical 
strength, as they were in mental capacity from the force of 
other institutions ; but both among them and the Romans, 
in the best times of their history, the strictest temperance 
formed a part of their character, and this was even blen- 
ded with their military establishments, so that their polit- 
ical power only declined as they became enervated by lux- 
ury. If the children of a delicate or strumous stock were 
properly trained up as to exercise and temperance, there 
would probably be much less disease in general, and of con- 
sumption in particular ; and by directing the minds of youth 
at the same time to intellectual objects, much of that dissi- 
pation and frivolity might be done away which now so fre- 



100 PULMONARY CONSUMPTION. 

quently disappoints the expectations of parents, and de- 
stroys the morals or health of their offspring. 

As a preventive of morbid conditions of the skin and 
of the lungs, I would mention the maintenance of the tone 
of the superficial vessels ; and I do firmly believe, from re- 
peated observations of its effect, that the almost daily use 
of the shower-bath, or cold ablution of the skin, is one of 
the best preventives of pulmonary consumption. In all 
cases where it is practicable, it is better to employ sea 
than spring water ; and when the former cannot be obtained 
a little common salt may be added to the latter, by way of 
stimulating the skin. In general the water should be about 
the temperature of 90° of Fahrenheit's scale, when the 
shower bath is first used ; and it ought gradually to be 
brought down to 60°, at which point it may usually be con- 
tinued the whole year round. But there are subjects who 
may bear it at last a little lower than 60°, and there are 
others who require it to be always a little higher. The ex- 
act point, however, will be easily ascertained by the feel- 
ings ; yet, as a general rule, it will be safer to have it above 
than below 60°, in delicate constitutions. On the employ- 
ment of the shower-bath, the head ought to be completely 
covered with an oiled silk cap, to keep the hair dry ; and 
immediately after it, the skin should be rubbed with coarse 
flannels, and a little warm tea or coffee taken as soon as 
possible. It is surprising how refreshing this procedure is, 
how it braces the whole animal fibre, and how light and 
elastic it renders the spirits ; but its grand influence is in 
giving an energy to the cutaneous vessels, which enables 
us to bear without injury the changes of the atmosphere ; 
and hence those persons who accustom themselves to it, 
are not only less liable to consumption, but to all sorts of 
visceral inflammations or excitements. The prevalence of 
congestive and inflammatory diseases might be greatly les- 
sened in this country by the general and proper use of te- 
pid and cold baths : and the legislator, who should procure 
their erection for the public benefit, would deserve the 
gratitude of the present and future times. But in defiance 
of all that we can do, still pectoral and other diseases will 
result from the great changes of temperature which our 
climate undergoes ; and as to the variations in the densi- 
ties of the air, we have no power over them ; although 



PULMONARY CONSUMPTION. 101 

pressing upon the surface of the body with different forces, 
they must occasion correspondent distensions, or contrac- 
tions of the internal vessels. This is a topic to which 
medical writers have not sufficiently adverted : yet there 
can be no doubt, that many internal diseases are partly de- 
pendant upon the alterations in the density of the atmos- 
phere ; and hence certain persons are like barometers, con- 
stantly changing with the weather. For all these reasons, 
therefore, how much soever our country may be endeared 
to us by social relations, how much soever we may venerate 
it for the great minds which it has produced, and for the 
patriotism, science, and philanthropy which- it still cherish- 
es, yet there are occasions which may compel us to leave 
it, and to seek a more settled and serene climate. In fact, 
wherever fair grounds exist for inferring the approach of 
the tubercular phthisis, the practitioner should not hesitate 
a moment to advise a voyage to another country: and 
where the circumstances of the patient preclude this, a reg- 
ulated temperature, an attention to the digestive organs, 
the removal of internal irritations, the use of ablutions, and 
the establishment of cutaneous sores by blisters, setons, or 
issues, will commonly be the best means of warding off 
the threatened attack. 

Connected with this part of the subject, it may be briefly 
noticed, that when there is a hereditary predisposition to 
phthisis, the old practice of making setons or issues in the 
skin ought not for the most part to be neglected ; and as its 
reasonableness may be inferred from the doctrines already 
laid down, so its utility has appeared to me evident in sev- 
eral examples. But when local external irritations of this 
kind are used, the setons or issues should be often renewed, 
new ones being made as the old ones are healed. When a se- 
ton or an issue has been allowed to remain open a long 
time upon the skin, the part becomes so familiarized to its 
action, that it occasions little counter irritation, and of 
course little benefit ; but when one is dried up and another 
made, as above mentioned, a counter irritation to a certain 
extent is constantly maintained, and the benefit is more 
strikingly displayed. But upon the whole, very small blis- 
ters, if I mistake not, are equal, if not preferable, to issues 
or setons, when applied in succession to different places, 
and kept open for some time by the savine ointment. Nev* 



102 PULMONARY CONSUMPTION. 

ertheless, the local external irritation should never be car- 
ried so far as to produce a general re-action of the heart 
and arteries 5 for when that is the case, the general re-ac- 
tion will of course extend to the capillaries of the lungs ; 
and thus the external local irritation may prove the mean 
of actually exciting what it was intended to prevent. In- 
deed I have known the general circulation of phthisically 
disposed patients so very excitable, that every common spe- 
cies of counter irritation on the skin was prejudicial ; and 
in such, the best way that the surface can be acted on fa- 
vourably, is by a regulated temperature, by an occasional 
emetic, by ablutions, by clothing, and by a change of clim- 
ate. The strumous person, who has open sores, is seldom 
liable to pulmonary consumption ; and when the sores by 
any chance heal, artificial ones ought to be substituted, else 
he may be in danger of falling at last into that distemper. 
From all the foregoing hints, I trust that practitioners will 
perceive the great importance of attending to the skin in 
their pathological inquiries respecting phthisis, and even re- 
specting other diseases, but this will be the more especially 
necessary where the consumptive or the strumous temper- 
ament is known to be hereditary ; since from an early adop- 
tion of preventive means, attacks on the vital organs may 
be successfully parried. In our times we have seen the 
most pleasing and beneficial change effected in the treat- 
ment of numerous diseases, simply by instituting an action 
on the tract of the bowels ; and as the skin affords a much 
larger surface for action, as it closely sympathizes with the 
internal parts, why may not certain expedients operate as 
beneficially through it, as others have done through the 
intestines ? 

Though loss of flesh and strength sometimes mark, as its 
pure effects, the approaches of phthisis, yet it cannot have 
escaped the observation of any medical man of experience, 
how very prone certain subjects are to tubercular phthisis 
from those circumstances which directly break up the gen- 
eral strength. Among the ordinary causes, therefore, of 
this complaint may be enumerated — various diseases, great 
fatigue of body or anxiety of mind, immoderate courses of 
mercury, excessive venery, improper use of vinous or spir- 
itous liquors, an indigestible, irregular, or very spare diet, 
sedentary employments, the giving of suck too long, and 



PULMONARY CONSUMPTION. 103 

copious losses of blood. Respecting each of these a few 
remarks shall be given, which may tend to illustrate the 
operation of all similar causes. 

Any class of diseases which produces general debility 
may lead to pulmonary consumption, and the greater the 
debility the more is commonly the risk of secondary disor- 
der : for in cases of extreme weakness, the vascular sys- 
tem is highly excitable from nervous irritation, this re- 
action may excite a pre-disposed organ into disease, espe- 
cially if aided by diffusible stimulants. Besides, it was 
before shown that, in such examples of universal collapse, 
it is in the minute branches of the arteries that the circu- 
lation is more particularly liable to be disturbed. If a ten- 
dency to phthisis, therefore, had previously existed, the 
capillaries of the cellular tissue of the lungs will be now 
most fitted for its excitement or production. It has always 
appeared to me one great advantage of the depletory plan 
in the early stage of fevers, that patients are not only far 
less liable to relapses, but likewise to the supervention of 
chronic diseases, than under the old stimulant treatment. 
It is unquestionably true that recoveries from fever have 
taken place under the protracted and precarious exhibition 
of excitants : but in almost all of such cases, which have 
fallen in my way, chronic inflammations of some of the vis- 
cera have followed ; and phthisis has been the most com- 
mon, which however will sometimes succeed after the best 
measures, in cold weather. Perhaps in civilized society, 
no human being is born with all his organs in a perfect con- 
dition. Some local weakness or other probably always 
exists in so complicated a machine ; and when the balance 
and harmony of health are disturbed by any general shock, 
the local weakness is then most liable to be apparent. 
Raro quisquam non aliquam partem corporis imbecillam 
habet,* is an observation which Celsus made about two 
thousand years ago ; and as it is founded on nature, it will 
be as immutable two thousand years hence, as at present, 
so superior is fact to conjecture. Whenever the body, 
then, has been enervated by disease, we should be very at- 
tentive even on the decline of the disease, and the more 
?o, if there be any hereditary predisposition ; because an 

* Lib. I. cap. iii. p. 20» 



104 PULMONARY CONSUMPTION. 

improper diet, a neglect of the bowels, or an incautious ex- 
posure to the air, might be followed by phthisis, or by some 
other affection. Under such circumstances it is not so 
easy, as at first sight appears, to make the diet exactly suit- 
able to the state of the constitution. If it be not sufficient- 
ly nutritious, the nervous irritation and the vascular exci- 
tability are increased ; if it be too nutritious, the already 
commencing re-action may be dangerously augmented ; and 
the only safe course which we can pursue is between these 
two extremes. It is impracticable at once to raise the 
body from the collapse of disease to the energy of health ; 
and every attempt of this kind arises from a disregard of 
the most obvious laws of the animal economy, and is always 
attended with danger. Artists who regulate watches scien- 
tifically know, that when they go wrong, it is best to bring 
them gradually to the ordinary movements ; and those who 
take upon themselves to restore the weak to strength, should 
be guided by a similar principle. The human body will 
bear a great deal if it be gradually done ; but it is often 
destroyed by too great and sudden shocks or changes. The 
appetite should never be pampered either in sickness or in 
convalescence ; and when the alvine evacuations are not 
proportionate to the ingesta, a laxative ought occasionally 
to be exhibited. Where the debility has been great, the 
quality of the food must be of the most digestible kind, and 
its quantity moderate : for by an impropriety either in the 
quality or quantity, assimilation may be disordered, and 
general irritation induced, with a train of morbid conse- 
quences. In health the powers implanted in the system 
are sufficient to sustain the action of the common bodies 
surrounding us, which then only stimulate us to a degree 
necessary for the various exercises of our functions : but 
in the debilitated habit, this balance of action and re-action 
is destroyed, and wonted impressions cannot be borne with- 
out the chance of vital injury ; and therefore, however 
common the custom, it is decidedly wrong to expose feeble 
convalescents to the open air, without due regard to its 
temperature and serenity. After recovery from fevers and 
other diseases productive of debility, phthisis frequently 
supervenes from too sudden and free an exposure to the 
atmosphere ; but this is more particularly the case after 
the measles, which so often leave much general debility, 



PULMONARY CONSUMPTION. 10£ 

and so strong a tendency to pectoral affections, from the 
previous excitements of the lungs or its appendages. On 
the abatement of all distempers which have greatly redu- 
ced the constitutional vigour, the clothing should be warm 
for some time afterwards, and the utmost care taken 
to guard against the influence of the cold. The whole. cir- 
culatory system remains long in a vacillating state ; and as 
the superficial vessels are especially weakened, so the shock 
of external impressions is easily communicated to the in- 
ternal parts. But the above precautions in respect to re- 
gimen, with the occasional use of the tepid affusions, will 
generally prevent secondary diseases ; and where a remov- 
al into a pure and temperate air can be accomplished, it 
will always most powerfully contribute to restore the gen- 
eral strength. When, however, in defiance of these pre- 
ventive measures, any signs of visceral excitement shall 
appear, the employment of moderate evacuants, with an 
antiphlogistic regimen, will be highly necessary ; but in 
every instance of this sort, the attendant irritation should 
be allayed by the warm bath, or by occasional opiates ; and 
if these expedients only be recurred to promptly, they will 
frequently remove an immediate, and prevent an ultimate 
disease. 

Bodily fatigue seldom induces phthisis, unless it be long 
or repeatedly endured, or unless it be connected with much 
anxiety of mind ; and under either of these circumstances, 
it may so break up the general health, as to lead to this dis- 
ease. Accordingly I have sometimes seen it follow hard ex- 
ercise on horseback, a long journey on foot, indiscreet tri- 
als of strength, and the like, especially when undertaken in 
intemperate weather. Nature intended the heart to beat, 
and the blood to revolve at a certain rate ; and though pro- 
vision has been made for great occasional exertion, yet that 
exertion cannot be often renewed without risk. In the first 
place, it hurries the circulation impetuously through all the 
vital organs, so that if any one be weaker than the rest it is 
liable to suffer ; and in the next, it is always succeeded by 
more or less collapse, which leaves the system open to the 
operation of ',.-ny other causes of disease. Disorganiza- 
tions of the viscera are often occasioned by ar. excess of cor- 
poreal labour. Yel nat ire has so c instituted us, that health 
cannot be preserved witnoui a certain measure of exercise : 

14* 



106 PULMONARY CONSUMPTION. 

and if we could always observe a medium in that respect, 
our lives would be more easy and more protracted. But 
the wants, forms, and duties of civilized society are fre- 
quently making greater demands upon the voluntary powers 
than can be safely supplied ; and the re-action thereby in- 
duced on other parts of the body often tends either to dis- 
order their functions, or to derange their structure. The 
persons whom I have known most frequently to fall into 
phthisis from fatigue, were delicate females who performed 
the offices of nurses, and those who visited night after night 
in fashionable parties. Urged by that sensibility, which is 
so conspicuous an attribute of the female mind, young wo- 
men often nurse their sick relatives or friends, and not un- 
frequently carry their attentions so far as to wait on them in 
the night as well as the day. Their feelings, too, are often 
strongly excited by the sufferings which they witness, and 
thus solicitude of mind is brought, to co-operate with the 
corporeal fatigue. The consequence often is, that their 
own health begins to decline ; and if they should happen to 
have any tendency to phthisis, they are almost sure to be- 
come its victims. Whenever, then, there is a known or 
suspected predisposition to consumption, such powerfully 
exciting causes as these should be avoided as much as pos- 
sible ; and the more so if the patient, with whom the pre- 
disposed person resides, labours under the true tubercular 
consumption ; as some facts have occurred to me which 
render it probable, that the purulent effluvia of the lungs 
may excite the disease in a peculiar habit. Nothing breaks 
up the strength sooner than the want of sleep at those hours 
which nature obviously designed for repose ; as they are 
marked, as well by the regular return of day and night, as 
by our own feelings, before perverted by artificial habits. 
Let any one attend to what he experiences within himself, 
and he will be satisfied, that the labour which is light in the 
day, is burthensome if borne in the night. The accumula- 
ted stimuli of the day are sufficient for the temporary ex- 
haustion of the excitable system upon which they act, and 
the abstracted rest of night is requisite to recruit us for the 
encounter of each successive day : and when we attempt 
to create a new sort of existence, by surrounding ourselves 
with artificial stimuli at nights, we cannot surely be surpri- 
sed if the premature loss of health should follow the violated 



PULMONARY CONSUMPTION. 107 

law of nature. It is the strange violation of this law in the 
fashionable world, that makes delicate females so liable to 
consumption ; and the loss of strength which they sustain 
operates the more forcibly, because it renders them suscep- 
tible of cold, to which they are perpetually exposed at the 
season in which visiting is most common. Those who pos- 
sess riches and rank have fallen upon many expedients to 
distinguish themselves from their inferiors ; but there is 
none more injudicious and dangerous than the present fash- 
ion of visiting during the night. Amongst the higher order 
of society, animal food is now eaten at almost all their meals ; 
and it is this circumstance, I suspect, which saves many of 
the delicate and dissipated females from phthisis ; for though 
persons of regular habits do not, so far as I have remarked, 
require a great deal of animal food, yet, under frequent 
night-watching, nothing tends to maintain the strength so 
much as meals of flesh meat. Where the least suspicion of 
a phthisical taint exists in any family, the members of it 
should studiously avoid visiting at nights, and observe the 
utmost regularity in their regimen. Few things contribute 
so much to preserve health and to prolong life, as going to 
bed early and rising early. On inquiry it will be found, 
that most of those persons who reach an extreme old age, 
have attended to these two circumstances ; nor can we be 
surprised at their influence, since they are so consonant to 
nature, and since they are generally united to a train of 
temperate habits. Literary and scientific men, whose 
modes of living in other respects are so different, yet often 
resemble fashionable people, inasmuch as they sit up when 
they ought to have been asleep ; and as their pursuits are 
most truly fascinating, and as the term of life seems almost 
too short for the accomplishment of great works, we cannot 
wonder that they should wish to employ some portion of the 
night, the silence of which is so suitable to reflection. Yet, 
in doing so, those who have an hereditary predisposition to 
phthisis, will not in the end lengthen, but on the contrary 
shorten the period of their labours, and even of their exist- 
ence ; and the young in particular will be apt to sink pre- 
maturely under studies pursued at nights, and therefore their 
acquirements should be made in the day-time. Anxiety of 
mind is often combined with bodily or intellectual exertion, 
and to their union we may sometimes clearly trace the first 



108 PULMONARY CONSUMPTION. 

symptoms of consumption. Anxiety of mind has a peculiar 
power over the heart, and also over the liver and other or- 
gans of digestion ; and it is by disordering them, that it ope- 
rates forcibly, though indirectly, on the lungs, or on the 
brain. 

In various places I have spoken highly of the efficacy of 
calomel as a febrifuge purgative and alterative, and in vari- 
ous places shall have occasion to do so again. But it has 
been distinctly noticed, and shall again be distinctly noticed, 
that this preparation can only be advantageously given in 
certain morbid states of the system, connected with arterial 
excitement, or with venous congestion ; and I am well as- 
sured by observation, that much mischief accrues from the 
use of mercury, without due consideration of the circum- 
stances under which it is administered. It is a common 
practice with many, to prescribe long courses of mercury 
for almost all chronic diseases of the internal viscera ; and 
the result not unfrequently is, that the strength of the con- 
stitution is shaken to its very centre, while no favourable 
impression has been made on the topical disorder or de- 
rangement. Nay, even in chronic affections of the liver, 
this medicine is far too indiscriminate!) and profusely given ; 
but the talent and industry of Dr. Farre promise in a great 
measure to correct this evil, by distinguishing those affec- 
tions more accurately than had hithertofore been done. — 
Yet if there be any one disease in which mercury is more 
abused than in another, it is undoubtedly in the primary 
and secondary syphilis — a disease which has long exercised, 
and which still exercises, an awful influence over society. 
From an improper treatment of the primary, the secondary 
syphilis succeeds ; and sometimes the mere local and con- 
stitutional irritation of the one or the other induces phthisis, 
which is, however, far more frequently the effect of the 
united agencies of mercury and cold. Whenever the sys- 
tem is not in a high state of arterial excitement, or in an 
oppressed one of venous congestion, the exhibition of mer- 
cury requires the greatest care. Now a certain degree of 
the inflammatory diathesis does exist both in the primary 
and secondary syphilis ; and it is this which enables us to 
prescribe mercury so often without prejudice to the general 
heaith in lues. But then we should recollect, that it is gene- 
rally so mild a degree of the inflammatory diathesis as to re- 



PULMONARY CONSUMPTION. 109 

quire a mild administration of the medicine ; and in those 
occasional cases, where the inflammatory diathesis runs 
high, we shall gain no advantage from it, nay, the system 
will uusally be impervious to its specific action, until we have 
premiseg 1 venesection or purgatives. Mercury cures syphi- 
lis upon the same principle as it cures simple inflammation. 
The common defects in giving mercury for the cure of lues 
are, first, its irregular, and secondly, its profuse administra- 
tion. If mercury be irregularly given, if the mouth be made 
sore one week, and be allowed to get well the next, and so 
on afterwards, the secondary syphilis will be very apt to 
follow the apparent cure of the primary disease ; and if, du- 
ring or shortly after the use of the mercury, the patient be 
allowed to go abroad in cold and variable weather, he may 
readily become consumptive. If, on the other hand, mer- 
cury be so profusely exhibited in the primary syphilis as to 
occasion a long and severe salivation, this also may break 
up the delicate system, and ultimately lead to phthisis. But 
the irregular or profuse employment of mercury is still more 
dangerous in the secondary syphilis. For that form of the 
disease is always attended with much constitutional derange- 
ment, and if this derangement be allowed to proceed by the 
irregular employment of mercury, or if it be increased 
by its too profuse administration, those who are predispo- 
sed may .apse into consumption ; and those who are not 
predisposed may sink under the unresisted syphilis, or, if 
they should escape that fate, may ultimately die from the 
combined influences of debility and organic disease of the 
viscera. During a course of mercury, whether short or long, 
the patient should be confined within doors ; and I would 
recommend practitioners to make this an invariable ruie of 
conduct in every case of syphilis. Both during and after a 
course of mercury, the nervous sensibility, and the vascular 
irritability, are often considerably increased ; and this more 
especially happens in strumous temperaments, and is the 
reason why they bear mercury so much worse than others. 
Now if patients be exposed to cold in this state, and if they 
have any tendency to visceral disease, that disease may be 
at once excited, so susceptible are the nervous and vascular 
systems to external impressions ; and it is on this account 
that 1 have frequently seen phthisis take place in young 
men, while going about their ordinary business, under the 



110 PULMONARY CONSUMPTION, 

influence of mercury. To guard as much as possible against 
consequences, not only should the syphilitic patient beware 
of cold both during and after his mercurial course, but he 
should endeavour to maintain the vigour of the system by a 
light and nourishing diet, by breathing a pure atmosphere, 
and by occasionally using the tepid bath. A mercurial at- 
mosphere, if the expression be allowable, and want of per- 
sonal cleanliness, often greatly debilitate and endanger the 
delicate ; and hence the impropriety of crowding a number 
of venereal patients into the same ward, as is sometimes done 
in public hospitals, and that too without the strictest regard 
to cleanliness. It may finally be remarked on this point, 
that mercury is peculiarly prejudicial to the true phthisical 
habit, since it excites the whole capillary system, in part of 
which the predisposition lies ; and therefore whenever the 
exhibition of this preparation may be necessary in such sub- 
jects, it should be given with the utmost caution, unless they 
labour under some highly inflammatory or highly congestive 
disease^ 

Excess of venery breaks up the general strength more fre- 
quently than has perhaps been suspected ; and it is some- 
times the latent cause of nervous affections, and occasionally 
paves the way to consumption in peculiar constitutions. On 
some occasions I have met with dissipated, or newly marri- 
ed men, whose digestive organs were greatly disordered 
from this cause, and who laboured under an irregular fever, 
with cough, expectoration, stitches in the side, and other 
threatenings of phthisis. But on strictly enjoining a sepa- 
rate bed, and prescribing a cool, simple, and nutritious diet, 
with medicines which moderately moved the bowels and 
corrected the vitiated secretions, all the disagreeable symp- 
toms have in general speedily disappeared. And on a few 
other occasions, where this injunction, and these regula- 
tions of regimen and medicine had been disregarded, the 
disease has passed on, until the structure of the lungs was 
destroyed. In the commencement of cases of this nature, 
there is generally a peculiar paleness of the face, with great 
relaxation of the whole skin ; and some degree of nervous 
tremor with occasional palpitation of the heart, are not un- 
common. Where nervous and pectoral symptoms are com- 
bined, an opiate now and then will be attended with much 
advantage ; but the almost daily employment of the tepid 



PULMONARY CONSUMPTION. 1 1 1 

shower-bath, the water being strongly impregnated with 
salt, will be found one of the best remedies, in conjunction 
with those above mentioned. Many anomalous symptoms 
proceed from the same source, and may be fatal when that 
source is not timely discovered by the practitioner ; but as 
their enumeration would be foreign to my present purpose, 
the hint is merely thrown out to put others on their guard 
with respect to what has not yet been sufficiently adverted 
to by medical writers. Celsus seems to have been aware 
of the importance of this subject, to which he has made 
strong and pointed allusions ; and it would appear from his 
writings, that the ancient Romans, of his time at least, were 
much more attentive to this point than the moderns : while 
history also informs us, that their admired predecessors, the 
Greeks, were fully conscious of its influence over the 
strength ; since those who contended for prizes at some of 
the Olympic games, were previously the subjects of an ab- 
stemious system. Certain it is, that a regard to this matter 
will often be found of great importance in the cure of chro- 
nic diseases ; and it is on this account, that I have been in- 
duced to advert to it so distinctly here. 

Nature has not only supplied the things which are abso- 
lutely essential for our support, but has also adapted them 
to the peculiarities of our constitution. That water was in- 
tended as our common drink, we have the most convincing 
proof in the abundant supplies of it which exist in almost 
every part of the world. To those whose taste has not been 
depraved by unnatural stimulants, water is the most pleas- 
ant beverage ; and no other fluid can be found which 
quenches thirst, assists digestion, and supplies the waste of 
the secretions so well. Whatever fluid indeed we take, it 
is the water in it which performs these offices, and the re- 
mainder is superfluous, if not injurious, in a condition of 
health and of strength. In civilized society, stimulants are 
accumulated, and tempt us to the temporary pleasure which 
they communicate ; and when satiated by one we too often 
have recourse to another, until at last health be injured or 
destroyed. At all times a considerable portion of our hap- 
piness consists in the gratification of mere animal feeling, 
such as hunger or thirst, and the like ; but as rational beings 
we ought to make that gratification subservient to the high- 
er enjoyments of which our nature is susceptible. So inti- 



112 PULMONARY CONSUMPTION. 

mate is the connexion between morals and medicine, that 
in his researches the physician must continually take into 
account the influence of the former on the health. Were 
the minds of youth early and steadily directed, first to the 
acquirement of moral and scientific information, and after- 
wards to the useful avocations, there would be much less 
dissipation, and of consequence much less disease. Some 
stimulus seems required to prevent us from sinking into 
torpor or ennui ; and where this stimulus is not supplied by 
mental recreations, and the practice of some business or 
profession, it will generally be sought in wine and similar 
excitants. If we do not give young men proper employ- 
ment, their passions will become the prey of surrounding 
temptations. These remarks are not so foreign to the sub- 
ject of consumption as might seem at first sight; since it is 
really lamentable to see how many young men die of that 
distemper, induced by drinking wine or ardent spirits, but 
especially the latter. It was once emphatically observed, 
by the present Professor Home of Edinburgh, that ardent 
spirit is the bane of human nature, and the most pernicious 
discovery ever made by art : — and I am thoroughly con- 
vinced, from long and repeated observation of its effects, 
that it is the cause of more vice and more disease than per- 
haps any thing else, among the lower and middle ranks of 
society. Its excessive use converts man into a ferocious 
brute, and occasions many untimely deaths. If mild malt 
liquor could be substituted every where for distilled spirits, 
the happiness and health of thousands would be annually 
preserved. It is easy to perceive how strong drinks, and 
particularly spirituous ones, may prove the excitants of pul- 
monary consumption, when they operate upon predisposed 
constitutions. Not only do they break up the general 
strength, by disordering the digestive organs and exhausting 
the nervous energy, but they propel the blood with preter- 
natural velocity through the lungs, so that the capillaries 
take on a diseased action, and tubercles are excited or pro- 
duced. Incases of this nature, it almost always happens, 
that the digestive organs give the firs* indications of disease : 
and it is curious to remark, how ihe prominent symptoms 
will sometimes be apparently in the liver at one time, and 
at another in the lungs ; until at last the latter are decided- 
ly attacked, and the progress of suppuration is then unusu- 



PULMONARY CONSUMPTION. lis 

ally rapid. If consulted at an early period, when phthisis 
is merely threatened, the medical man may often be of great 
service to those who have been addicted to the excessive 
use of wine or spirits, both of which he must positively pro- 
hibit ; but at the same time it will generally be requisite to 
substitute small repeated doses of opium for a time, with a 
moderate allowance of mild ale. This change in the mode 
of living, aided by a light diet, and such laxative and alter- 
ative medicines as correct a vitiated state of the abdominal 
secretions, will sometimes accomplish more than might have 
been expected, in a threatened attack of phthisis. 

Those who pamper their appetites, or gorge themselves 
perpetually with rich food, and those who fast long or take 
their meals irregularly, are apt to suffer from disorder of the 
digestive organs ; and if they should chance to have a ten- 
dency to phthisis, it may ensue as an ultimate effect, the 
precession of the one disorder being in them often closely 
allied to the supervention of the other. But if any person 
possessing this tendency suddenly change from a simple to 
a complicated diet, he will the more readily relapse into 
consumption, especially if he at the same time change from 
an active to a sedentary life, or from a quiet and regular, 
into a noisy and dissipated one, where late hours are kept. 
Occasionally I have been able to refer distinctly the origin 
of the pectoral symptoms to some such alteration in the 
mode of living. Where the patients did not become deci- 
dedly phthisical, they hadacopious flow of phlegm apparent- 
ly from the trachea and the branches of each bronchion, at- 
tended with less or more affection of the liver; and where 
this flow did not take place early, but a hard dry cough ex- 
isted, the lungs were seemingly irritated into suppuration $ 
so that in affections of the liver, I am inclined to think the 
lungs are sometimes saved from disorganization by an early 
and copious expectoration. It appears to be the most fa- 
vourable effort which nature could make for their preser- 
vation, and whenever it is wanting the danger will most 
probably be augmented in the phthisical constitution. Dr. 
Rollo long ago remarked the near alliance between certain 
disorders of the digestive organs and of the lungs, but till 
lately the subject has not attracted sufficient attention. An 
inquiry into incipient examples of this complicated nature, 
will almost always show that the excreta are not propor- 

15* 



PULMONARY CONSUMPTION* 

tionate to the ingesta ; and there is a wasting of the flesh, 
without any night-sweats or similar causes to account for 
it ; we are at once led to attribute it to an imperfect assimi- 
lation. The root of the tongue is almost always white in 
the mornings, the breath in some degree unnatural, and 
these are throughout more or less apparent ; while the face 
and lips frequently acquire a cadaverous sort of paleness, 
and the skin feels flaccid. The patient generally rises lan- 
guid, recruits a little in the course of the day. and is almost 
invariably most lively towards the evening ; but upon the 
whole his spirits are variable, and subject to sudden depres- 
sions and elevations from circumstances which would have 
hardly influenced him in health. The urine commonly va- 
ries much in colour and in quantity, and the alvine evacua- 
tions always indicate a vitiated state of the abdomtnal se- 
cretions. If early adopted and steadily pursued, a light 
simple diet, the compound rhubarb pill at night, and the 
Harrowgate sulphureous water on the following morning, 
with an occasional blue pill, very small repeated blisters, 
and regular habits in going to bed and rising, will most fre- 
quently ward off phthisical attacks. When these prevent- 
ive measures do not seem to operate speedily, a change of 
climate should be recommended, through a pretty long 
voyage by sea : and where that cannot be undertaken, a 
regulated temperature must be substituted in an airy apart- 
ment, if the weather should be cold. But whenever the at- 
mosphere is mild and clear, exercise on horseback or in a 
carriage, or sailing upon the sea or a river, may be recom- 
mended with probable advantage. 

Too spare or too poor a diet often produces consequen- 
ces not unlike to those of too full or too rich a diet ; and 
the pathologist will find, however seemingly inconsistent, 
that similar effects are perpetually flowing from opposite 
causes. In too spare or too poor a diet, there is not suffi- 
cient to supply the waste of the various secretions, the wear 
and tear of the animal machine, and thus the vital princi- 
ple languishes with the movements to which it is connect- 
ed : — whilst by too full or too rich a diet, the digestive func- 
tions are so much oppressed, that a sufficient quantity of 
nutriment cannot be prepared from the ingesta for the gen- 
eral support, and hence too. emaciation follows. Among 
the improvident members of the lower orders of society 




PTLV 

: often aherratifif of 
^ad what fhey eara iaj 
perfects a re *"ery liable to I 

-.xm&cl-- • x-iwioi; that iew becsae < 

i the tooe of the 
iropfey lactic nie^s ire- therefc-T 
qgence to avoid too rich or in© fill a d>et oe the cae biLiA 
and too poor mad scanty a Set «n the efeer 
among the h ighest a&d b¥«! rar^- we shaB Ad polmaBa- 

zsvmptKm sifeii^ fro:a both these cacj?e= 
ha bat? : while those are iatinrrrfrr aore 

rapila i it y. lla m Bf any species of food teuSs to dfe»: 
rsass store than psstry . which i? 
ri in aM coadztiorjs of fife. 
me ir: ~ or to recnminrid a spaie £e 

vrf hereiitsiry rrei :=z :sei :■: . :r_?_~:r :i i_ : ± . . 
kaow mot _pon what special prete 
done, yet Ass I kaow. that it very ofrei 

3d 1 cas lbr~ 
have generally seex soch sife^ i&zt 

iod da: animal food, with a SfctSe miii 

fresh ale. Exceptions 

--.: i? hi~;:i :■: :^ irit n : : f :i: ::"_-: - : ^ : -:~li- 

tioa aad a forid complexion are com&raed witt: 

the ¥ e die Issgs. Preserve tbe i -. - 

those who hare aa hereditary teode : 

place them ia seesrtty : bre.il 

or any other mea&s. and yoa hazard the 

pli:«:f i is : '" ::i2':::; :* :: i . :*.i z _- — : •? : ± : . *- 

to preserve simplicity m ar 

-^posed of fewer articles* aod were these tc»Wd 

*fih- 
ful, Almost every hretc i tijmiU x: 
iture or by accident!, ana:: 

; 
of Mtare in the choice of iood ; thrash mir 

ItfaMt 

be were the sport n»d the victim «f«&5 



116 PULMONARY CONSUMPTION. 

appetites. Nor is it to be expected, that after having ad- 
vanced so far from the instincts of nature with respect to 
our food, that we can safely return to a simple and frugal 
mode of living ; for our very constitution has been altered 
by artificial habits, and wholly to give up those habits would 
be to hazard health, or even life, by the shock. But the 
consideration of these circumstances does not preclude the 
necessity and safety of a gradual and rational change in our 
manner of diet ; and if our dishes were fewer and plainer, 
if we substituted mild ale* or water for vinous and distilled 
liquors, and if our hours of going to bed and rising were 
earlier, there cannot be a doubt but consumption and many 
other organic diseases would be less common. 

The state of the population of Great Britain has under- 
gone a great change. The main body of the people for- 
merly existed in the country, it now exists in large towns. 
It is not my business to investigate the causes of this change ; 
I have only to point out some of its effects as connected 
with disease. Almost all the inhabitants of large towns 
may be considered as following sedentary employments : 
for what are large towns but so many manufactories, where 
men ply their several trades in a contaminated atmosphere ? 
Among some, it is true, the sphere of action is more extend- 
ed than among others, but hardly any of them are ever 
braced by the exercises and air of the country, which are 
congenial to our nature, and without which we languish 
more or less, like vegetables transplanted from their native 
soil and climate. The old mode of building cities in the 
East, interspersed with cultivated fields and plantations, 
must have been infinitely more conducive to health than 
the modern plan of huddling houses together as closely as 
possible; and though we are not now able to carry it by 
any means so far, still we might advance our welfare by 
imitating the ancients in this department of domestic econ- 
omy. In proportion to the population, the number of 
deaths is much greater in our large towns than in the coun- 

* From observation I am persuaded, that porter is often not a whole- 
some liquor, though it is now so generally drunk. I strongly suspect 
that it frequently contains considerable portions of opium, or of some 
similar drug, which acts specifically in distending the vessels of the 
brain, and thereby it becomes a powerfully exciting cause of palsy and 
apoplexy — diseases which have certainly increased of late years. 



PULMONARY CONSUMPTION. H7 

try ; and, if my own observation be correct, pulmonary 
consumption is far more prevalent in the former, the pop- 
ulation being supposed equal in both. There is more lux- 
ury and dissipation in large towns, more of mental anxiety^ 
and less of bodily exertion without doors ; and much must 
also be attributed to the impurity of the air, though some 
chemists persist in telling us, that it is the same in the town 
as in the country. If we timely observe the breaking up of 
the general health of an inhabitant of a large town, and 
send him into the country, we thereby often prevent the 
developement of some organic disease, such as consumption. 
Though pale and emaciated when he went away, yet prob- 
ably he returns ruddy and fat ; and all this change has been 
produced without the aid of medicine. Now how are we 
to account for this ? Doubtless it was partly dependant 
upon the greater regularity as to rest, diet, and rising, to 
the refreshing influence of the scenery, and to the intermis- 
sion of those cares which, with an immense weight, press 
upon the mind of those actively engaged in the world, as 
the surrounding atmosphere presses on the body. But af- 
ter all these allowances, we are compelled to ascribe a great 
deal to the influence of the atmosphere : and accordingly 
we find, that patients themselves are conscious of its eflica- 
cy from what they daily feel. From the mere difference 
of complexion one may almost know at a glance the inhab- 
itant of the country from that of the town ; and this differ- 
ence is chiefly attributable to the influence of the atmos- 
phere which they respectively breathe. The good effects 
of a country air no doubt are connected with its purity, but 
when electricity is better understood, it will perhaps be 
found that this fluid has some co-operative power; and 
though the subject has not yet engaged the attention of 
medical philosophers, it can hardly be a question, that the 
electrical states of the atmosphere in the town and country 
are widely different. Probably the immediate cause of 
people in the town being more liable to consumption than 
those in the country, is simply that the former are not so 
strong, and of consequence that they are more readily act- 
ed on by the exciting causes than the latter. 

The extension of the manufacturing system has operated 
morally and physically to the detriment of thousands, how^ 
ever beneficial it may have been to the world at large. 



118 PULMONARY CONSUMPTION. 

The young, the middle-aged, and the old, are commonly 
crowded together in many of the large manufactories, even 
without due regard to the distinction of sex, and in the 
most unwholesome places and employments ; and some of 
them are daily exposed to noxious or irritating inhalations, 
which must act as direct excitants of consumption where 
any latent predisposition lurks. Indeed, the general health 
of this class is continually broken up by the influence of 
their situation, and by the dissipated, irregular, or unnatur- 
al habits which they contract ; and hence among them, per- 
haps more than among any other description of people, are 
seen the various developements of scrofula, and phthisis of 
course has it's share of victims. But one of the most mel- 
ancholy results of the manufacturing system is the exces- 
sive selfishness which it has engendered even in parents : 
so that they frequently begin to value children as mere la- 
bouring animals of interest, almost as soon as they can run 
about ; and accordingly coop them up to earn money by 
some noisome work, when they should have been unfolding 
their affections, and establishing their strength. This is a 
fertile source both of crime and of disease ; for it is un- 
reasonable to expect that such children should generally 
be either virtuous or healthy. Many of them fall prema- 
turely into consumption and similar diseases 5 and most of 
those who survive have sickly bodies and depraved minds. 
It were to be wished that such cruel sacrifices should cease 
to be made ; and it is especially lamentable that they should 
so frequently happen in a country which abounds with more 
true philanthropy than any other. Children should not 
if possible be sent to any very laborious or sedentary em- 
ployment before the age of puberty ; and where necessity 
demands it sooner, the work should be proportionate to 
the powers of the child, which ought to be allowed free ex- 
ercise in the open air every day. The health of various 
manufacturers, and of labourers in mines, might be benefit- 
ted by a strict attention to their morals and comforts, to 
the ventilation of the apartments where they labour, and 
by the erection of baths to promote personal cleanliness ; 
and even expedients might be invented to guard them in a 
great measure against the inhalation of those noxious par- 
ticles or effluvia, likely to subject them to consumption, or 
to any other distemper. There is a principle of improve- 



PULMONARY CONSUMPTION. lie 

ment implanted in our nature, which has gradually raised 
us from a savage to a civilized state ; and it cannot be rea- 
sonably doubted that the future operation of this principle 
will tend to ameliorate our condition in many departments 
of life. In speaking of sedentary employments, I cannot 
refrain from alluding to one circumstance particularly, be- 
cause it is connected with the medical profession. When 
young men enter upon the study of medicine, they occa- 
sionally break up their general strength by the intensity of 
their application in the dissecting room, in the tainted air 
of an hospital, or in their own apartments, and may actu- 
ally become consumptive from this cause. The impression 
upon the general health first becomes evident from an uni- 
versal paleness of the skin, by some loss of flesh, and by 
some derangement of the digestive organs ; and it is gen- 
erally under these circumstances, that a tickling cough 
steals on day after day, and if it happen to be too long dis- 
regarded in the true phthisical habit, it may at last end in 
suppuration of the lungs. In all cases of this kind, study 
should be wholly intermitted. A removal into the coun- 
try, mild laxatives, simple diet, an occasional blue pill, and 
small blisters, will commonly be requisite; and provided 
these be early adopted, they will generally prevent the ac- 
cession of phthisical symptoms. 

Few circumstances debrlitate the body more than giving 
suck too long, and therefore we find this a common cause 
of phthisis in the lower orders of society, where the sys- 
tem is not proportionably supported with nutritious food. 
It is not unusual among women of this class to suckle their 
children until they are nearly two years old, with a view of 
retarding pregnancy again, and saving an immediate ex- 
pense. While a child is at the breast, the menses are gen- 
erally suspended, and on this account pregnancy is com- 
paratively rare at that time. Nine months is a sufficient 
time for any woman to give suck, and in some who are 
naturally delicate, that period is much too long. But when- 
ever children are weaned, the bowels of the mother should 
be kept gently open, and her diet should be light for some 
time, by way of moderating or preventing the arterial re- 
action which is apt to succeed such an event. Many causes 
concur, in giving suck too long, to reduce the strength of 
the system ; but the principal are the excessive drain from 



120 PULMONARY CONSUMPTION 

lactation, the fatigue of carrying the child, whose weight if 
constantly and greatly increasing, and the interrupted sleep 
at nights. The united influence of these is exceedingly 
powerful where a previous disposition to consumption pre- 
vails ; but more especially if the nurse should be frequent- 
ly wet by the child, and neglect to change her clothes, as 
the operation of cold is then added to that of the other 
causes. Where there is the least suspicion of any tenden- 
cy to phthisis, the greatest attention should be paid to 
those who give suck : the child ought to be weaned much ear- 
lier than usual, and the mother should as much as possible 
avoid fatigue, wet, disturbance at nights, and in short,what- 
ever weakens. It is particularly improper to pamper the 
appetite at this period, with pastry, wine, cordials, savoury 
meats, and the like. Both for the sake of the mother and 
the child, the diet should be simple but nutritious at the 
same time : since if it be too complicated or too spare, it 
may equally disorder the digestive organs, destroy the gen- 
eral vigour, and thereby in some prove the occasion of tabes 
of the lungs. When any pectoral symptoms of a phthiscal 
tendency have arisen during nursing, the child ought to be 
weaned with all expedition ; and it is surprising what a 
favourable influence this will sometimes exert, in combina- 
tion with a proper regimen. That diet will be best in 
such a case, which supports the constitutional tone with- 
out exciting the heart and arteries. Flannel or fleecy ho- 
siery should be worn next the surface, the child should not 
sleep in the same apartment with the mother, lest it break 
her rest ; as for medicines, the mildest laxatives occasion- 
ally, and the smallest blisters, will be all that are usually 
necessary. 

It is well known, that women subject to large uterine he- 
morrhages, are very apt to become consumptive ; and in- 
deed copious losses of blood of all kinds seem capable of in- 
ducing phthisis, in patients in whom a latent predisposition 
to it had before existed. Copious losses of blood not only 
exhaust the constitutional powers immediately, but they are 
invariably followed by an agitated sort of re- action through- 
out the whole arterial system ; so that if any part of the 
body had been previously weaker than the rest, tht peculiar 
re-action here specified excites it into actual disease. In 
fact, the causes which have just been enumerated operate 



PULMONARY CONSUMPTION. 121 

in a way similar to hemorrhage ; for they first break up the 
strength, and are followed by an arterial re-action connect- 
ed w'ith much nervous irritation ; and in this state the most 
delicately or defectively constituted organ suffers the main 
shock of that arterial re-action. It is a remark as old as 
Celsus,* that debility renders the body highly obnoxious to 
all diseases ; but the remark may be applied with peculiar 
force to diseases of an excitive nature, among which con- 
sumption must be classed. The stronger the body, the less 
liable it is to all disorders of the circulation. Debility has 
a singular power in augmenting the irritability of the whole 
capillary system of the arteries ; and as consumption is a 
disease immediately seated in these arteries of the lungs, so 
the causes which produce debility ought to be studiously 
avoided, by those who have an hereditary tendency to that 
disease. It requires the most cautious procedure to treat 
patients properly, who have had copious hemorrhages. If 
they be excited by strong food or drink, an impetuous re- 
action supervenes, which may induce an active inflamma- 
tion of some internal viscus ; as we frequently see peritoni- 
tis occasioned after delivery by a stimulating regimen, rash- 
ly adopted to relieve the temporary feelings of exhaustion. 
On the contrary, if they be kept too low, the nervous irrita- 
tion is augmented, and that again re-acts on the vascular 
system, and irregular determinations of blood are the ulti- 
mate effects. In short, as before hinted, we must adminis- 
ter a light cool diet to patients thus debilitated, which will 
support without exciting them, and the present irritation 
must be allayed, not by wine, but by opiates ; and whenever 
the tide of arterial re-action returns, we must moderate it 
by a suitably antiphlogistic regimen and evacuants, among 
the last of which, purgatives are generally the most appro- 
priate. 

It is a common opinion of medical writers on this subject, 
that hsemoptoe is one of the most frequent causes of con- 
sumption, but I cannot implicitly subscribe to this opinion. 
Heberden justly observes, in his Commentaries, that epis- 
taxis is rarely a primary affection ; and it may be similarly 
affirmed of haemoptoe, which almost always arises out of 
some other disease. Sometimes it is the effect of a suppres- 

* Lib. I. cap. iii. p. 23. 

16* 



122 PULMONARY CONSUMPTION, 

sion of menstrual or hemorrhoidal discharges, at other times 
of an obstruction in the liver or spleen, and not unfrequently 
it is a consequence of an increased action on the tracheal or- 
bronchial lining ; and when proceeding from accidental 
causes of this nature, it does not readily produce phthisis, 
unless under gross mismanagement, or in those who are 
known to be hereditarily predisposed to that distemper. — 
Nay, when blood is spit up from the lungs of persons thus 
predisposed, it is nine times out of ten not the cause, but 
the consequence of tubercles, which had previously existed 
in the lungs ; and it is not therefore correct to make con- 
sumption a common termination of hasmoptoe, as many 
writers have done. There may be, and I believe there are, 
some solitary cases in which the retention of bloody coagula 
in the body of the lungs excites them into suppuration ; but 
this suppuration, I suspect, is more frequently of the ordi- 
nary than of the true phthisical kind. It is in peculiarly 
organized lungs, and perhaps in them only, that a rupture of 
vessels will produce genuine phthisis ; and when the loss 
of blood is large, it may operate unfavourably through the 
local irritation of the lacerated part, and through the shock 
which it gives to the constitution. But an alarum is too 
often indiscriminately sounded, when blood is expectorated, 
as if the case were utterly hopeless. We should ascertain 
its source and the habit of the patient, before we give a de- 
cided opinion. If it should be found to have proceeded 
from the suppression of some accustomed discharge, from 
some disease of the liver or spleen, or from some tracheal 
or bronchial irritation, it may be most frequently removed 
by correcting the local derangement, where the phthisical 
taint is absent ; and truly in all of such examples, it is to 
be regarded as an immediate effort of nature to free the 
system from some topical surcharge of blood, which threat- 
ened to disturb the regularity of its functions. Yet where, 
on the contrary, there is reason to suspect that the spitting 
of blood is connected with a phthisical tendency, or with 
the actual existence of tubercles, the danger is always im- 
mediate ; and we should then not only give a most guarded 
prognosis, but deliberately pause before we venture upon 
the treatment, as the precipitate and free use of the lancet, 
or any other highly exhausting measure, might entirely der 
feat the chances of recovery. 



PULMONARY CONSUMPTION. 123 

In concluding the hints upon the causes which ultimately 
occasion consumption by breaking up the general strength, 
it ought not to be omitted, that those causes operate power- 
fully on the skin from first to last. Debility never occurs 
without the skin singularly participating in its influence. 
When the general health of any one is on the decline, we 
most frequently first remark it by the face becoming of an 
unnatural paleness ; and if we extend our observation, we 
shall find that this paleness is diffused over all the surface of 
the body. A complete change indeed has taken place in 
the state of the whole capillary system of vessels in the skin ; 
and the very nervous condition of that organ has likewise 
undergone a correspondent alteration, for powers now act 
upon it with greater force than before. The bulk of the 
body haPs diminished, the skin is withered like an autumn 
leaf, and the patient shrinks from the impression of a cool 
atmosphere, which formerly invigorated his whole frame. 
It is in this very state that the pectoral symptoms common- 
ly appear, and we may often trace them to an accidental 
cold ; and where this is not the case, the mere changes in 
the densities of the atmosphere, by varying the pressure on 
the surface, may sometimes affect the lungs. Be it con- 
stantly recollected, not only that the skin is a fine expansion 
of nerves and blood-vessels minutely interwoven with the 
cellular tissue, but that between that sensitive part and the 
vital organs within, there is a strong reciprocal consent ; 
and in fact, what is the ultimate structure of these organs, 
but a seeming modification of the skin itself, a continuity of 
the same fine and sympathetic fabric of nerves, vessels, 
and cellular membrane ? Now in all cases of general debil- 
ity, this sympathy between the surface and the centre is 
rendered more exquisite. It is on this account in general, 
that internal inflammations or excitements are then most rea- 
dily produced by outward impressions ; and it is on this ac- 
count too in particular, that consumption so frequently ari- 
ses from the influence of cold at that time. It is not, how- 
ever, intended by these remarks to insinuate, that general 
debility cannot lead to consumption but through the medi- 
um of the skin ; for it has been already shown, that con- 
sumption may directly arise from debility, through a conse- 
quent disturbance in the capillary arteries in the lungs, fa- 
voured by an inherent predisposition. Butithas neverthe- 



124 PULMONARY CONSUMPTION. 

less appeared to me from repeated observation, that phthis- 
is does very often follow general debility in the circle above 
described — the condition and functions of the skin being 
first changed by the debility, and some external impulse, 
such as that of cold air, afterwards acting morbidly but in- 
directly on the lungs through the skin. In the same mode, 
and to the same agency, may occasionally be traced the rise 
of those abdominal affections with which phthisis is some- 
times complicated ; but it is the liver which more frequent- 
ly suffers in this secondary way from impressions on the sur- 
face, than the rest of the digestive organs. 

The condition of the skin, in conjunction with other symp- 
toms, may enable us to form the diagnosis of the true tuber- 
cular phthisis. In the advanced stage of this complaint, 
when suppuration has taken place, the diagnosis is*most ob- 
vious, but of little practical utility, for at that time medical 
aid is almost always unavailable. It is therefore most de- 
sirable that we should if possible detect the disease when 
the tubercles^re either forming in the lungs, or when, having 
previously existed, they are first roused into irritation by an 
incidental cause. It appears to me, that the first changes 
which indicate the approach to phthisis are to be found in 
the skin. The colour of the cheeks always becomes paler 
and more delicate than before, while that of the lips is often 
of a brighter red. If the practitioner place himself directly 
opposite to the patient, and look steadfastly on his face for 
some time as he converses with him, he may generally ob- 
serve the colour come and go in a surprising manner. A 
beautiful bloom will be spread for a moment over some part 
of the cheeks, and then receding it will leave a remarkable 
pallidity, almost approaching to whiteness. Whenever this 
symptom is obvious, with a pulse somewhat quicker than 
natural, and a short tickling cough, phthisis may always be 
apprehended. It must be distinctly understood that I am 
now speaking of an incipient or a threatened phthisis, for 
the above observations will not obtain at all its stages. At 
this period, too, the whole surface appears paler than in 
health, and the superficial veins may be observed running 
in different parts of the skin, somewhat like blue lines 
through white marble. The hair, from some change in the 
cutaneous secretion, frequently loses its natural brightness, 
is laxer or softer, and acquires a dingy or dirty shade ; and 



PULMONARY CONSUMPTION. 125 

whatever pains may be taken, it will hardly ever remain 
well in the ordinary mode in which it was dressed. The 
eyes undergo striking alterations, and with them the ex- 
pressions of the countenance. The tunica adnata, which 
may be almost considered a modification of the skin, mostly 
becomes of a faint bluish white colour, and the eye has a 
glassy or glistening appearance ; and an expression of in- 
terest, and even of beauty is not unfrequently thrown over 
the whole countenance, very remarkable in persons whose 
face had been previously plain. This change is most man- 
ifest in females, on account of the greater delicacy of their 
skins. The tongue generally participates in these morbid 
variations of the cuticle, so that its surface for the most part 
becomes smoother and frequently a little redder than for- 
merly, except in those cases where the digestive organs are 
disordered at the same time, and then it is often rough and 
white. The temperature of the skin is never perfectly nat- 
ural from the first. It is chilly and hot, cool or warm by 
turns, and some degree of fever may generally be detected 
after a full meal, though it is most apparent towards night. 

In the true tubercular phthisis there is an early tenden- 
cy to partial perspirations in the night, but at first they are 
commonly very slight ; and when they do not exist, it will 
usually be found, that the patient passes an abundance of 
urine, so intimate is the relation between the skin and the 
kidneys. Indeed there is a circle of nervous and vascular 
sympathies in the pulmonary, renal, and cutaneous organs, 
the investigation of which might throw some new light on 
many diseases. In combination with the above symptoms 
may be mentioned the confidence of mind which generally 
attends the approach or invasion of phthisis; for though 
there be a manifest loss of flesh and strength, an elevation 
of spirit seems to lift the patient above his bodily sufferings, 
or at least to make him aimost insensible of his weakness. 
Hence it is that many subjects of incipient phthisis can 
hardly be convinced of the necessity of any restraint in re- 
gard to regimen, and have themselves an assurance in their 
own health fully proportionate to the fears of those who 
are interested about them. There are doubtless some ex- 
ceptions to this state of mind, but they chiefly happen when 
phthisis is combined with some other disease ; and Dr. 
Philip has therefore, generally speaking, justly made de- 



126 PULMONARY CONSUMPTION. 

pression of spirits a distinctive mark of that species of con- 
sumption which supervenes an affection of the liver. As 
the simple tubercular consumption advances, the hope of 
recovery may remain, even when the structure of the lungs 
has been destroyed ; and we sometimes hear patients, ac- 
tually dying, confidently predict the period when their 
health shall be re-established, and when they shall again 
pursue their favourite schemes of life. Mental anxiety 
and corporeal oppression attend most of the common forms 
of fever, and it is one of the peculiar characteristics of the 
true hectic, that they are either wholly absent, or only 
present in a partial degree ; a circumstance which proves 
that the sensorium, the chief material medium of mental 
and of voluntary power, participates less in the phenomena 
of this, than of ordinary fevers. It is still a common opin- 
ion, that hectic arises from the absorption of pus : but facts 
surely occur every day to overturn this opinion. Large 
collections of matter are often found under the integu- 
ments, and even running sores exist on the skin without the 
least tendency to hectic ; and if the absorption of matter 
were the cause of that fever, it is difficult to conceive why 
it should not occur in cases apparently so favourable for 
absorption. Every body knows, too, that hectic takes 
place in diabetes when there is no secretion of pus : and 
practitioners of experience must have met with it in other 
diseases where much irritation occurred, without any in- 
ternal or external suppuration ; at least I can assuredly as- 
sert, that I have known hectic to supervene independently 
of the presence of pus in any part of the body. Neither 
can hectic be said to depend simply or solely upon local 
irritation, since of it asymptomatic fever of the common 
type is the general result ; and yet hectic perhaps never 
exists without some irritation, which shows that they are 
related. Some concurrent, accessory state of the constitu- 
tion seems required to make irritation produce hectic ; and, 
without specifying what that state is, it may be truly affirm- 
ed, that hectic never arises but when the system at large is 
peculiarly affected. In the tubercular phthisis, next to the 
appearance of pus in the sputa, perspiring during sleep is 
perhaps the most certain sign of suppuration in the lungs, 
when taken in connection with the hectic, and with the 
*ough. To ascertain this point, I have visited patients at 



PULMONARY CONSUMPTION- 127 

all hours of the night, and invariably found some part of the 
skin moist in sleep, if that sleep had been ever so short: 
and it may be observed in this place, that the sleep is gen- 
erally very short, and at unequal intervals, in the genuine 
hectic of consumption. This disposition to sweat during 
sleep, often manifests suppuration of the lungs in phthisis, 
before any pus can be observed in the expectoration. In 
the true tubercular consumption, the pus is most frequently 
expectorated in circumscribed and almost circular pieces, 
blended with mucus ; so that if the patient be ordered to 
spit into a basin of water, each piece in it appears , some- 
thing like a small cockle which had just been stripped from 
its shell. This form of the sputa, however, is not uniform- 
ly found in phthisis, but it far less seldom occurs in chro- 
nic inflammation of the bronchia, in ulcers of the trachea, 
or in chronic and common suppuration of the lungs them- 
selves, in all of which pus is commonly expectorated in a 
more diffused, irregular form, and of a more liquid consis- 
tence. Having now alluded to some of the most important 
topics in the pathology of this disease, I shall next proceed 
to the treatment of the forementioned affections which re- 
semble it, and afterwards offer a few remarks on that of 
phthisis itself. 

For chronic inflammation of the bronchia, a change of air 
ought to be recommended as early as possible, provided 
the weather will permit it without risk to the patient. In 
the hooping cough which, when confirmed, may often be 
practically considered as a species of chronic inflammation 
of the bronchia extending up the trachea to the glottis, a 
change of air is highly beneficial ; and sometimes it is scarce- 
ly less so in the affection here specially discussed, which 
arises from cold and other accidental causes. So much de- 
bility usually results from chronic inflammation of the bron- 
chia, that we can rarely bleed copiously with any advan- 
tage ; but small, general, or moderate local bleedings are 
sometimes very useful, when followed up by blisters near 
the site of the disease. In habits greatly emaciated, we 
ought commonly to prefer local to general bleeding ; for, 
whatever the latter might promise at first sight, the trial of 
it will most frequently disappoint our expectations. It 
were fruitless to attempt at once to change a long estab- 
lished inflammation by a powerful impression on the gen- 



128 PULMONARY CONSUMPTION, 

eral system. That impression might break through the 
comparatively weak associations of an incipient, but it will 
rarely succeed in a confirmed disease : nay, it would most- 
ly do greater injury to the constitution, than service to the 
local disorder. There are certain diseases, in the removal 
of which the practitioner should resemble the cautious and 
dexterous angler, who tries various expedients to entangle 
his prey, and then gradually expends its force before he 
considers it finally secure. When however an acute su- 
pervenes a chronic inflammation of the bronchia, venesec- 
tion must be promptly and decidedly used, because in that 
case, a new disease has taken place, the rapid nature of 
which requires immediate and powerful measures. But 
even then we must have a regard to the prior disorder, and 
not carry our depletion so far as we would in a patient 
whose health and strength had been previously unbroken. 
Neither in the strictly chronic inflammatory of the bronchia 
ought the general bleedings to be often repeated, even when 
small or moderate at each time ; but after the first or se- 
cond cautious use of the lancet, we should trust to occa- 
sional leeching and blistering, when the symptoms seem to 
demand further applications which have a speedy influence. 
An antiphlogistic regimen should always be adopted, and 
where milk agrees it will constitute the best article of diet, 
as it supports the strength without exciting the heart and 
arteries ; but even where milk alont- disagrees, it may fre- 
quently be made very digestible by mixing it with equal 
parts of soda water. 

Among the medicines administered internally, the balsam 
of copaiva deserves to be conspicuously placed, as it is 
among the best remedies with which I am acquainted, in 
chronic inflammation of the bronchia and similar affections. 
It seems in many cases to exert a specific influence over 
the mucous membrane of the trachea and its branches, it 
increases the flow of urine, it not unfrequently keeps the 
bowels regularly open, and sometimes it acts upon the skin, 
causing an itching or an eruption. Upon the single or 
combined influence of one or other of these effects its main 
efficacy probably depends. At first it should be given, on 
soft water or in fine mucilage, in doses of about thirty or 
forty drops three titftes a day, and gradually increased af- 
terwards, until sixty, eighty, or more drops be taken at each 



PULMONARY CONSUMPTION. 129 

time : but where it obviously and shortly lessens expecto- 
ration, the cough and irritation, it will seldom be requisite 
to increase it to the last mentioned dose ; and where it does 
not speedily produce such effects, it often will be necessa- 
ry to increase the dose to more than that amount. In some 
it occasions sickness, in a few it acts as a strong cathartic. 
The sickness may often be prevented by combining it with 
some aromatic water, or a very minute quantity of the 
spirit of wine ; and to restrain its purgative operation, a 
little camphorated tincture of opium may be added to each 
dose. But an occasional nausea or even vomiting is most 
frequently of benefit in chronic inflammation of the bron- 
chia ; indeed, whenever there is an oppressive accumula- 
tion of phlegm, an emetic ought to be administered. This 
is a point of great consequence to recollect; for many pa- 
tients have been suffocated in this disease, for want of the 
opportune exhibition of an emetic. Yet nausea as well as 
vomiting, though both are occasionally very useful, should 
not be too often nor too long excited, especially in a deli- 
cate habit, lest they weaken the digestive powers too 
much, and through them the whole system. It may, 
therefore, be sometimes necessary to withdraw the copaiva 
when it operates in either of those ways. In regard to ex- 
cessive purging, it invariably does harm, and ought to be 
guarded against with care ; but a moderately laxative ac- 
tion must be maintained on the bowels, otherwise the breath- 
ing may become oppressed, or the circulation of the cere- 
brum disordered. Castor oil and the Harrogate sulphure- 
ous water are the two best laxatives in such cases; and, 
when the bowels do not act moderately under the use of 
the copaiva, the one or the other should be given early in 
the morning, that it may operate long before bed-time. In 
September, 1817, I was attending a lady who had been some 
time under my care, and who had had an enlargement of 
the thyroid gland for a considerable period, which latterly 
acquired a scirrhous hardness, and pressed so much upon 
the windpipe as to occasion many of the symptoms of the 
disease in question. If her bowels were constipated for a 
single day, she was affected with spasms of the upper, and 
great numbness of the lower extremities, twitchings about 
the face, much nervous agitation, and an uncomfortable 
feeling in the head. All these symptoms subsided as soor 

17* 



130 PULMONARY CONSUMPTION. 

as two or three full motions were procured by castor oil, or 
some similar aperient. But when I first attended her, if 
the purging were carried much further than this, she was 
very apt to become oppressed in her breathing, so nice a 
point was it then to relieve the nervous, without aggrava- 
ting the pectoral symptoms : and in most chronic affections 
of the bronchia, to say nothing of the acute, moderate purg- 
ing is useful, and excessive purging prejudicial. In the case 
just mentioned the patient found decided relief from the 
copaiva as an expectorant. It deserves to be noticed by 
the way, that in some other instances of enlargement of the 
thyroid gland which have come beneath my inspection, dis- 
order of the digestive organs existed. When a general ir- 
ritation is excited, whatever may be the cause of it, a pre- 
ternatural accumulation of blood takes place in that part 
which had a previous tendency to disease. But to resume 
the consideration of copaiva. It was before noticed, that 
this balsam sometimes causes an itching or an eruption of 
the skin, both of which often give great alleviation to the 
cough ; and where either of them does not appear service- 
able in that respect, the copaiva ought to be omitted for a 
time, particularly if any dyspeptic symptoms be present, 
which it now and then produces. Copaiva combined with 
sulphur was the favourite remedy of Morgagni in chronic 
complaints of the lungs, and 1 have often exhibited them 
with manifest advantage. Both these medicines have been 
too much neglected in coughs by modern physicians, but 
they were once held in high estimation. The older chem- 
ists called sulphur the balsam of the lungs, from the then- 
current opinion of its efficacy ; and when we consider that 
it has a specific action on the skin, we cannot be surprised 
if it should be sometimes very useful. But among those 
measures which chiefly operate through the skin, the warm- 
bath ought not to be forgotten in bronchial inflammation, 
whether chronic or acute. Its occasional employment not 
only brings a flow of blood to the surface, which at once re- 
lieves the labour of the lungs, but it likewise contributes to 
allay fever and irritation, and thus has a two-fold influence 
in affections of this nature. The patient, if possible, should 
breathe an atmosphere of a moderate and equable tempera- 
ture, which is sometimes extremely beneficial in alleviating 
the cough, and acting gently on the skin ; whereas the reS* 



PULMONARY CONSUMPTION. 131 

piration of a cold or variable medium often aggravates the 
cough, and repels the blood from the surface. 

An intelligent friend prefers the rectified oil of turpentine, 
in chronic inflammation of the bronchia, to most other 
means ; and though I have seen it succeed remarkably in 
some cases, and fail in others, yet my own experience of it 
has not afforded sufficient data for a fair appreciation of its 
general powers in this dssease. It may be exhibited, mixed 
in water by mucilage or yolk of egg, in doses of about thir- 
ty drops at first, two or three times a day ; where it is found 
to lessen the cough and expectoration, it may be grad- 
ually increased, but where it occasions any thing like gene- 
ral irritation it ought to be speedily withdrawn. 

In chronic inflammation of the trachea or its branches, 
the exhibition of opium alone requires much caution. It 
has a specific action on the cerebral vessels, by which the 
lungs themselves are sometimes secondarily affected, pro- 
bably from some degree of consequent pressure near the or- 
igin of those nerves which communicate with the pulmonic 
system. In all cases of fulness in the cerebral vessels, the 
respiration is impeded or oppressed : and when exhibited 
alone in full doses, opium certainly does tend to check ex- 
pectoration, perhaps upon the principle just explained. But 
this specific operation of opium is exceedingly modified by 
combining it with small doses of calomel, of camphor, and 
of antimonial powder ; and accordingly this combination, 
the dose of opium being moderate, rarely checks expectora- 
tion, for it determines so much to the skin, as rather to re- 
lieve than to oppress the lungs. Where it seems inadmis- 
sible from weakness or some other circumstance, and where 
an anodyne is still required, a little of the camphorated tinc- 
ture of opium, or of the compound powder of ipecacuan, 
will be the best substitute, each of which has a similar 
though less powerful effect on the surface. Dr. Hamilton, 
of Lynn Regis, one of the best practical physicians of his 
time, speaks highly of calomel and opium in chronic affec- 
tions of the mucous membrane investing the air passages : 
but it may be regarded as an axiom, that medicine is less 
efficacious in chronic than in acute diseases. Cordially, 
therefore, as I join in the general and strong commendation 
of these two agents, preceded by evacuants, in acute inflam- 
mations, it is only justice to confess, that they have not un~ 



132 PULMONARY CONSUMPTION. 

frequently disappointed my expectation in chronic ones *. 
yet where the ordinary measures fail, they certainly deserve 
a fair trial even in simple chronic inflammation of the bron- 
chia ; though the opium should be moderately administeied, 
and mostly along with camphor and antimony for the rea- 
sons before stated. When, however, an hepatic affection 
is co-existent with a chronic inflammation of the bronchia, 
small doses of calomel at night, with as much of the sulphu- 
reous Harrowgate water on the following morning as will 
purge effectually, are often extremely beneficial. But in 
delicate constitutions it will be better to substitute the blue 
pill, or mercurial frictions over the region of the iiver, as 
these affect the general system less than calomel; and where 
there is an obvious te/idency to the tubercular phthisis, even 
the blue pill and the blue ointment must neither be long 
nor largely administered, lest the general strength be there- 
by shaken, and the capillaries of the lungs excited into dis- 
ease under that condition. The mild use of the blue pill 
or of the blue ointment, an occasional blister to the side, 
with a light plain diet, and the steady perseverance in the 
Harrowgate sulphureous water, will be more safe and effi- 
cacious than any other plan, in those who have a phthisical 
taint combined with an affection of the liver. 

In the first volume of the Medical Communications of 
1784, Dr. Samuel Chapman published a practical paper on 
pulmonary and other complaints, apparently supported by 
fever of the intermittent and remittent kind, and cured by 
the bark. He was led to the use of this remedy from hav- 
ing observed, during his attendance upon a case, that the 
patient was, in a manner, free from fever in the day-time : 
that the paroxysms had regularly returned at nearly the 
same hour every evening; and that the urine, on the sub- 
sidence of the sweat, deposited a laterious sediment, whilst 
it was clear at the top. In short, the febrile exacerbation 
about the beginning of the afternoon, the branny sediment 
at the bottom, and the greasy appearance on the surface of 
the urine, were all wanting in this case ; and as these are 
the general attendants of the true pulmonary hectic, he 
concluded that the case was not genuine phthisis, though 
the expectoration was purulent. He reports other cases 
of a similar character, all of which readily yielded to the 
exhibition of the cinchona ; and though he does not attempt 



PULMONARY CONSUMPTION. 133 

any explanation of their seat and pathology, yet they were 
obviously instances of chronic inflammation of the bronchia, 
attended with an intermittent or remittent form of fever.* 
This paper is highly important in a practical view ; and as 
the history, diagnosis, and treatment of chronic inflamma- 
tion of the bronchia are still very imperfect, it is well cal- 
culated to stimulate inquiry, as well as immediately to con- 
vey useful information. In the earlier part of my practice, 
I believe that I occasionally confounded pure cases of chron- 
ic inflammation of the bronchia with tubercular phthisis ; 
and having known others of more experience than myself 
do the same, I am anxious to fix the attention of medical 
men on the subject, that it may be more thoroughly inves- 
tigated. When the sputa are found purulent, and in com- 
bination with slow fever and night-sweats, it is no uncom- 
mon thing to pronounce the case hopeless ; and yet many 
an instance of this kind may be merely chronic inflamma- 
tion of the bronchia, which under our ordinary measures, 
not unfrequently admits of a cure, but which, from neg- 
lect, or want of information, is also not unfrequently fatal. 
It will be perceived, that 1 have mentioned many reme- 
dies for chronic inflammation of the bronchia, and, in cit- 
ing the paper of Dr. Samuel Chapman, have added bark 
to the number. The same disease, it is notorious, may be 
cured by different measures ; and the same disease, too, 
may actually require different measures, from the term of 
its duration, from the habit of its subject, and from other 
peculiarities. But still this complexity of prescription ar- 
gues a defective state of information on the subject. It 
shows, indeed, that we are not yet, from the cautious ob- 
servation of particulars, arrived at sound general principles 
in the therapeutics of this disease, to say nothing of the 
pathology. The measures, in truth, which are above re- 
commended, have been so far from generally successful, 
that I have sometimes felt it my duty to prescribe others j 

* The paper of Dr. Samuel Chapman was pointed out to me by an 
excellent practitioner, who had himself recently and successfully tried 
the bark in. a bad case of the same description. It. appears from a 
quotation which Dr. Badham has given, at page 46 of the first edition 
of his valuable essay on Bronchitis, that Stoll had used the bark bene- 
ficially in certain chronic affections of the bronchia, which resembled 
phthisis. 



134 PULMONARY CONSUMPTION. 

and among these have been ipecacuan and digitalis, the 
last of which has occasionally succeeded, where every thing 
else had previously failed, and its success seemed to depend 
upon its reducing the action of the heart. How others 
may feel I do not know ; but in reflecting upon the state 
of our materia medica, it appears to me much in need of 
improvement. Most writers on the subject have pre-sup- 
posed that the operation of medicines is the same, or sim- 
ilar, in sickness as in health. Hence many of the circum- 
stances of disease, which exceedingly modify the operation 
of opium, antimony, mercury, purgatives, and other impor- 
tant agents, have been overlooked ; so that we neither ac- 
curately know when these agents are indicated, nor contra- 
indicated in a great variety of interesting complaints. If 
the conditions of the system under which medicines were 
exhibited had been carefully marked, with their several ef- 
fects under those conditions, we might now have been in 
possession of sufficient facts to draw general and correct 
inferences respecting their influence and application ; but 
this is a work which yet remains to be accomplished, and 
I have merely alluded to it here, that men of inquisitive 
minds may turn their powers to a department of medical 
science, the cultivation of which promises almost more 
than any other. Many articles require to be erased from 
our pharmacopoeias, and we want precision in the applica- 
tion of those most commonly employed, all of which is at- 
tainable by assiduous observation of the sick ; but it is al- 
so to be expected, in the progress of knowledge, that some 
new agents may be discovered, which will greatly extend 
the efficacy of our art. 

Before, however, concluding the treatment of chronic in- 
flammation of the bronchia, I must caution the practitioner 
not to exhaust the powers of his patient by too rapid or too 
long succession of expedients ; and this is an error inta 
which we are very apt to fall in the treatment of many 
chronic diseases, from an anxiety to alleviate or remove 
some prominent system : so that when one measure fails, 
we recur to another, until at last the accumulated irritation 
of unsuccessful applications is added to that of the disease, 
which of course is finally aggravated. Where none of the 
most promising medicines act beneficially in chronic inflam- 
mation of the bronchia, a long voyage to a warm climate 



PULMONARY CONSUMPTION. 135 

should be immediately recommended. This simple change 
sometimes succeeds better than any other means, and in- 
deed it will seldom fail when early adopted. But where 
the season of the year or some other cause prevents us from 
carrying this measure into effect, a regulated temperature 
must be adopted in its stead ; care being taken at the same 
time to have the same apartments properly ventilated, by 
removing the patient from one to another at convenient pe- 
riods. Late in the autumn of 1816, I was consulted by a 
gentleman who was deemed to have strong consumptive 
tendency by some of his friends, but I found him labouring 
under chronic inflammation of the bronchia, complicated 
with dyspepsia and some affection of the liver. He was 
extremely pale and emaciated, very short of breath, wheez- 
ed, coughed, and expectorated much every morning ; but 
he had no night sweats, and his pulse was only about 86 in 
the minute, except in the evenings, when it usually rose a 
little higher. As the winter was then fast approaching, as 
a removal from home might have immediately exposed him 
to cold, and as he was a mail of fortune, r advised him to 
shut himself up in a suite of rooms, guarded by double win- 
dows, and a regulated temperature. Under this plan, to- 
gether with an occasional blue pill, a mild purgative, sim- 
ple diet, and a short trial of the balsam of copavia, he pas- 
sed the winter over tolerably well ; and though the pecto- 
ral symptoms were occasionally increased by accidentally 
taking an indigestible meal, yet he sailed to the Mediterra- 
nean in the following spring better than he had previously 
been. This gentleman now and then tried the inhalation 
of aether, but it did not seem to be of any service to him ; 
though I have known it and other fumes of benefit, by re- 
moving the morbid state of the membrane which lines each 
bronchion. The inhalation of the vapour of heated pitch 
or tar is a favourite remedy among some of the lower or- 
ders of society in bronchial defluxions ; and this affords a 
strong presumption that it must have formerly been used by 
physicians, as most popular remedies have descended to 
the public through the faculty. I have not yet seen suffi- 
cient of the effects of this remedy, to enable me to esti- 
mate its general powers with any thing like precision ; but 
an instance occurred to me where it occasioned an acute 
attack of inflammation of the windpipe, and I have met 



136 PULMONARY CONSUMPTION. 

with a few others in which it produced an insupportable ir- 
ritation of that part. The vapour of burning pitch has re- 
cently been recommended by a most respectable authority 
as a remedy for the tubercular phthisis itself, in the ad- 
vanced or suppurative stage; and though one might be 
inclined to suspect, that the cases apparently cured by it 
had simply been instances of chronic inflammation of the 
bronchia, yet any measure which holds out the most dis- 
tant hope of success merits a fair and full trial. 

Hippocrates was acquainted with ulceration of the trachea, 
for he expressly recommends those affected with a hot ulcer, 
called aphtha, in the aspera arteria, to avoid the wind and 
the sun;* and iEtius taught that ulcers near the extremity of 
the aspera arteria, or in the extremity itself, were curable 
by keeping the patient in a supine posture, and by raising 
the head with pillows to a considerable height. t In the 22d 
letter and the 2d book of his work on morbid anatomy, 
where the above two references will be found, Morgagni mi- 
nutely details the cure of one Stephen Cheli, a man of rank, 
who had long been troubled by a cough, purulent and bloody 
expectoration, with a sense of pain a little below the larynx, 
and in no other part. From this combination of symptoms, 
and the absence of a continual fever, he detected the dis- 
ease to be an ulcer in the trachea, which had been mista- 
ken for consumption by other physicians, to whom he al- 
ludes in a style of singular modesty and simplicity, in every 
way worthy of his mind. First of all, he ordered the patient 
to shut himself up in a warm chamber neither low nor close ; 
and there giving up all business rather to hear his acquaint- 
ance, than to talk much himself, and when he did, to speak 
in a low and slow tone. Having found that woman's milk 
agreed very well with him, he made his patient suck about 
half a pint from the breast of a healthy nurse, morning and 
evening. He likewise informs us, that he took particular 
care in directing her to use proper aliments, and to avoid 
variety of them as much as possible. The neglect of this 
circumstance he considers is the only reason why the milk 
of women is not better than the milk of animals for medical 
purposes, and adds that Euryphon and Herodotus preferred 

* De Morb. 1. 2. t. apud Salium 112 & 114. 
j Medic. Tetrabibl. 3. Serin, i. c. 64. 



PULMONARY CONSUMPTION. 137 

it to others in consumptive disorders, as it was familiar to 
us, and of the same nature with ourselves. In this remark- 
able case, wine, and every thing else that might be injuri- 
ous, was carefully avoided : the dinner and supper of the 
patient consisted of a pudding made of barley-flower with a 
little china-root, but without sugar ; and these ingredients 
being mixed up with milk, drawn fresh from a cow which 
had been fed upon barley and chaff, were reduced into a 
kind of calx over a slow fire. This regimen was strictly 
observed from the end of November to the middle of May, 
and the result was, that the patient recovered, and remain- 
ed well for sixteen years afterwards. As this was generally 
esteemed to have been a case of consumption, Morgagni ob- 
serves, that there were no consumptive persons in the city 
who did not prescribe the same method to themselves, but 
not one of them escaped.* This case may show us how 
much may be done by those minute regulations of diet and 
the like, which we are perhaps too liable to neglect as things 
of minor importance ; but in conducting the treatment of 
chronic diseases, attentive observation will convince us, that 
without the conjoined efficacy of a proper regimen, medi- 
cine can generally do little or nothing. 

It was formerly observed, that the most distinguishing 
mark of ulceration of the trachea, is pain, soreness, or some 
species of uneasiness referred to a particular part of the 
windpipe, in combination with purulent sputa; and if to 
this diagnostic sign a peculiar difficulty of breathing, with 
oppression of the praecordia, and a loss or hoarseness of the 
voice, be superadded in any case, we may be fully assured 
of its nature. Mr. Bedingfield remarks, in his valuable 
compendium of medical practice, that every case of ulcera- 
ted larynx and trachea which had fallen under his observa- 
tion, terminated fatally ; and, with the exception of two in- 
stances which manifestly arose from syphilis, and which 
were early detected, my experience has been equally un- 
successful in this disease. Both these cases were cured by 
saturating the system rapidly with mercury, and by main- 

* For a more detailed account of this case, the reader may consult 
vol. i. p. 666, 667, 668, of The Causes and Seats of Diseases investi- 
gated by Anatomy. Translated from the Latin of John Baptist Mor< 
gagni, by Benjamin Alexander, M. D. In three volumes. London : 
printed for A. Millar, and T. Cadell, his Successor, in the Strand. 1769 

18* 



138 PULMONARY CONSUMPTION 

taining its specific action for some time. That part of the 
trachea, which anatomists distinguish by the name of lar- 
ynx, is perhaps most liable to ulceration ; and when the 
ulceration is seated there it is more rapid in its progress and 
more violent in its character, than when seated in any other 
part of the windpipe. From the generally fatal tendency 
of ulcers of the trachea, the ingenious author above men- 
tioned asks, whether it would be adviseable to make an 
opening into the trachea or larynx, and apply such substan- 
ces to the sore as might excite a healthy action on its sur- 
face 5 and, apparently by way of giving force to this query, 
he mentions having seen several ulcers on the skin, which 
bore a strong resemblance to those of the larynx, cured by 
the application of nitrate of silver. . The operation here 
suggested, however hazardous it may appear, deserves an 
additional claim to our notice from two circumstances, which 
Mr. Charles Bell has communicated in the first part of his 
Surgical Observations. This scientific surgeon performed 
the operation of laryngotomy on a woman for a disease of 
the larynx, which threatened instant suffocation ; and it was 
observed, that the air drawn into the artificial opening op- 
pressed the respiration, probably from inspissating the mu- 
cus, or drying the lining of the pulmonary passages. To 
remedy this defect, the patient instinctively wrapped a little 
lint about a probe, dipped it in water, and then put it into 
the wound, allowing the water to drop down the windpipe, 
as it appeared to facilitate the respiration, and the dislodge- 
ment of mucus. * If one substance can be thus put into 
the windpipe, why may not another ? But this is not a 
mere question for consideration, the thing has actually been 
performed. In a female patient, whose epiglottis appears 
to have been destroyed by ulceration, Mr. Charles Bell as- 
certained, by passing his finger over the root of the tongue 
downwards, that the glottis was rough and irregular with 
ulceration ; and as the case seemed all but desperate, he 
repeatedly touched the glottis with a pad of lint fastened to 
a wire and dipped in a strong solution of nitrated silver.! 
So far from this bold treatment exciting irritation, it was 

* See Part I. p. 29, 30, of Surgical Observations, being a Quarterly 
Report of Cases in Surgery. By Charles Bell. London : printed for 
Longman & Co. 1816* 

f See part 1. p. 35, 36, 37, of Surgical Observations, &c. 



PULMONARY CONSUMPTION. 139 

attended with the most soothing and beneficial effects. Mr. 
Charles Bell was led to it from considering the relief which 
this caustic solution gives in common sores, in ulcers of the 
cornea, and in irritable spots of the urethra. The above 
circumstances afford a strong presumption, that the opera- 
tion which Mr. Bedingfield has suggested, might be under- 
taken with a chance of success in some cases ; and where, 
humanly speaking, no other mean is left to assist the patient, 
why should not this be tried as the last resource of our art ? 
And yet in cases of extreme emergency, tracheotomy ought 
not to be deferred too long, whatever may be the ulterior 
determinations of the operator ; for where it is delayed be- 
yond a certain period, a serous effusion takes place into the 
lungs from the continuance of their preternatural labour, 
and then it can do no good. 

The foregoing facts hot only suggest the occasional pro- 
priety of a local application, through an external opening, 
to an ulcer in the windpipe, but they seem to indicate the 
probability of benefit from the use of certain vapours or 
fumigations ; indeed where the difficulty of breathing is not 
so great as immediately to threaten life, perhaps some va • 
pour or fumigatiou may hereafter be discovered to answer 
all the purposes of a solution of lunar caustic applied direct- 
ly to an ulcer of the windpipe. At the same time it is cer- 
tain, that ulcers of the trachea are often but the last effects 
of insidous inflammations, the early symptoms of which 
have not yet been accurately detailed ; but it is to be hoped, 
that practitioners will hereafter mark and illustrate those 
symptoms, and thus enable us frequently to prevent what 
we now find so difficult to cure. In the secondary syphilis, 
however, ulceration of the windpipe sometimes apparently 
arises without any intermediate stage of inflammation, or 
the ulceration is at least almost simultaneous with the in- 
flammation : yet this does not invariably obtain, for at other 
times the ulceration in the trachea appears to follow as an 
extension of that which had primarily existed in the fauces. 
It is well known, that those who are subject to lose their voi- 
ces from cold or similar causes not unfrequently have puru- 
lent expectoration at last, and they are usually supposed to 
die of genuine consumption. But though such persons are 
unquestionably liable to lapse into phthisis, yet they are 
sometimes affected with ulceration of the trachea, a disease 



140 PULMONARY CONSUMPTION. 

which has often been mistaken for the former. Whenever 
we are called to any patient- with a hoarseness, attended 
with some disturbance of the respiration, we should be most 
minute in our inquiries, and cautious in our treatment : 
since these two symptoms may be the concomitants of that 
obscure species of inflammation which produces an ulcer in 
some part of the windpipe. In venereal ulcers of the 
throat, we should be especially attentive to the state of the 
voice and respiration, that we may not allow an ulcer to in- 
vade the larynx unawares. The voice is always changed in 
a venereal sore-throat, the patient speaking through the 
nostrils with a sort of sharp metallic sound ; but when the 
windpipe becomes ulcerated, he generally speaks as in a 
thick hoarse whisper, and has an irritating cough, while his 
respiration is more or less uneasy, and even spasmodically 
affected at times. In the chronic hoarseness, which arises 
from cold or other irritants of the windpipe, no remedies 
are so useful as emetics, copaiva, a regulated temperature, 
and occasional blisters and laxatives ; but the hoarseness 
which owes its origin to syphilis requires, like every other 
symptom of that disease, its specific remedy. Many cases 
of secondary syphilis are accompanied by loss of flesh, gen- 
eral debility, paleness of the skin, and some degree of fever 
at nights • and, especially if there be an ulcer in the throat, 
a tickling cough is apt to be present, so that the character 
of the case might appear truly consumptive, but for the pe- 
culiar concomitants of lues. The practitioner should there- 
fore be constantly on his guard, lest from a first impression 
of the constitutional and pectoral symptoms, he might over- 
look the real nature of the disease and omit mercury : on 
the other hand, he ought to be equally attentive not to mis- 
take a simple and genuine phthisis for any modification of 
syphilis ; since, however excellent mercury may be in the 
latter, it is by no means appropriate to the former. In 
common ulcers of the trachea, copaiva appears to be worthy 
of a trial, as it often acts favorably in inflammations of that 
part. 

Chronic inflammation of the pleura is very often remedi- 
able if it be early and properly attended to, but when it has 
exsited for some time the best measures will generally fail. 
In its first stage, before effusion has taken place in the tho- 
rax, one or two small or moderate bleedings from the arm 



PULMONARY CONSUMPTION. 141 

ought mostly to be premised. Afterwards leeches and 
blisters should be applied repeatedly and reciprocally to 
the chest, in conjunction with daily diuretics, occasional 
laxatives, and an antiphlogistic regimen. If these meas- 
ures prove unavailable, the mouth must be slightly affected 
by calomel, and the recently dried and powdered squill ad- 
ministered, as soon as the ptyalism occurs, and gradually 
increased in quantity until it acts powerfully on the kid- 
neys. The operation of calomel as an alterative in such 
instances is highly useful, but it ought generally to be given 
with small doses of opium, which allay irritation and pro- 
mote a determination of blood to the surface. Exhibited 
while the system is under the influence of mercury, squill 
is often an excellent diuretic, and from this property it tends 
to alleviate affections of the pleura and to ward off serous 
effusions within the bag of that membrane. But for squill 
to be efficient as a diuretic it should be given whilst it is 
fresh ; and the principal cause of its frequent failure is, 
that the preparations of it, which we commonly prescribe, 
have been too long kept in the shops. The upper poles of 
the bed should be raised eight, ten, or twelve inches, by 
placing blocks of wood under them, as before mentioned ; 
or a frame, with an equal elevation, should be made of the 
size of the bedstead, and fastened to it by screws, and upon 
this frame the bed or mattrass must be laid. An inclined 
plane, such as is here described, frequently enables pa- 
tients to sleep with some degree of comfort, who would 
have otherwise passed most uneasy nights. Of course a 
foot board is requsite whenever the bad is thus raised at the 
top, to prevent the body from sliding down. The temper- 
ature of the sitting and bed rooms should be regulated ac- 
cording to the feelings of the patient, and to the state of the 
skin : but it should seldom be below 60°, else there will be 
a danger of inducing chillness of the surface, a circum- 
stance which is apt to aggravate the pectoral symptoms. 
Jn the last stage of chronic inflammation of the pleura, 
when serous effusion in the cavity of the chest, or suppur- 
ation in the lungs has supervened, the efficacy of medical 
agents generally amounts to but little. For the removal 
of effused serum, a cautious and continued trial may be 
made of digitalis and squill, with a light infusion of colum- 
bo and the carbonate of potass : and where these do not 



142 PULMONARY CONSUMPTION. 

answer by themselves, the system should be put gently un- 
der the influence of mercury ; and the digitalis and squill 
being then again administered, they will sometimes act as 
powerful diuretics. The whole class of diuretics often fails 
before the administration of mercury, and sometimes suc- 
ceeds after it, a fact which must have been long familiar to 
many experienced practitioners. When an abscess exists 
in the body of the lungs, we do not know, with certainty, 
of any remedy which operates as a vulnerary to the part. 
But by placing the patient in a mild fresh atmosphere, by 
administering an emetic occasionally to relieve laborious 
respiration, and by supporting his strength with nourishing 
food, nature will now and then be enabled to effect the re- 
covery. The common swing will often be useful as a pal- 
liative for the extreme dyspnoea which so frequently attends 
hydrothorax or an imposthume in the lungs ; and I have 
been sometimes struck to see in confirmed consumptions 
how easily patients seemed to breathe under this motion, 
while every other greatly disturbed the respiration. 

When chronic and simple inflammation attacks the par- 
enchyma of the lungs in the first instance, the treatment 
must be pursued upon the same principles as in chronic in- 
flammation of the pleura ; but in the former it is probable, 
that considerable advantage might be derived from digitalis, 
which is frequently serviceable in the incipient stage of the 
latter, when sufficient depletion has been premised. In all 
inflammatory affections of the pulmonary organs, the lungs 
ought to be exercised as little as possible; and therefore 
both motion of the body, loud or long conversation, and the 
like, should be prohibited. An interesting anecdote is told 
of Malebranche, which may serve to illustrate this particu- 
lar. In the year 1715, Berkeley had an interview with 
that celebrated man. " The conversation turned on the 
non-existence of matter. Malebranche, who had an in- 
flammation in his lungs, and whom Berkeley found prepar- 
ing a medicine in his cell, and cooking it in a small pipkin, 
exerted his voice so violently in the heat of their dispute, 
that he increased his disorder, which carried him off a few 
days after."* From Mr. Dugald Stewart,t it appears, that 

* Biog. Brit. Vol. II. p. 251. 

f Seep. 122 of Dissertation First: exhibiting a general view of 
Metaphysical, Ethical, and Political Philosophy, since the Revival of 



PULMONARY CONSUMPTION. 143 

this was the only interview which these two memorable 
persons had : and however striking it may be in a biograph- 
ical point of view, one cannot but regret that it ever took 
place ; since it seems to have been the immediate occasion 
of shortening the life of one of those gifted individuals, 
whose labours form the materials upon which the minds of 
others are engaged for the instruction of mankind. 

When any of the foregoing affections exists in phthisical 
habits, iturequires the more care not only on account of its 
immediate disturbance, but also on account of what it might 
ultimately occasion ; yet whenever we are compelled to 
bleed such habits, we must make the depletion as moderate 
as the existing circumstances will permit ; for we must never 
fail to recollect that very copious losses of blood may be an 
indirect cause of consumption, and that in persons heredi- 
tarily predisposed to it, moderation is the golden rule as to 
venesection. This remark even obtains in such persons 
when they are attacked by an acute or sub-acute inflamma- 
tion of the pulmonic system, or indeed of any other part. 
We must certainly attempt at once to remove the inflamma- 
tion by decisive means, otherwise we place the life of the 
patients in immediate jeopardy , and it would be gross im- 
becility to stand deliberating about a distant arid contingent 
danger, and to allow a present and perilous disease to ad- 
vance without interruption. Nevertheless, a judicious phy- 
sician would not only promptly encounter the present dis- 
ease in persons of this description, but he would also if pos- 
sible, take care, that while his measures were directly effica- 
cious, they should not be so powerful as eventually to lead 
to another disorder. In all highly acute diseases, the lan- 
cet b the right arm of medicine, perhaps calomel the left. 
But at the same time the mode of application of each of these 
powers requires to be varied according to the age, constitu- 
tion, and other circumstances, even in ardent fevers : and 
where we have grounds for suspecting a consumptive ten- 
dency, we ought generally to procure the purgative with- 
out the alterative operation of calomel, after the discreet 
employment of the lancet. The modifications of the 
strumous temperament were before pointed out : one, in 

Letters in Europe. By Dugald Stewart, Esq. F. R. SS.— In Vol. I. 
Part I. Supplement to the Fourth and Fifth Editions of the Encyclo- 
pedia Bjitannica. 



144 PULMONARY CONSUMPTION. 

which, with the other known indications, the skin is natur- 
ally pale, and the circulation sluggish 5 the other, in which 
the circulation is naturally brisk, and the complexion san- 
guine. The last bears depletion much better than the first, 
but in both, excessive evacuations of blood are liable to 
break up the general strength^ and as I consider, in com- 
mon with many writers, that phthisis is nothing more than 
scrofula of the lungs, it may easily be called into existence 
by too much depletion, like every other modification of 
scrofula. Neither must our attention be solely confined to 
the removal of an acute, or of a sub-acute or chronic in- 
flammation in phthisical habits, but we must extend our 
solicitude throughout the whole of the convalescence, lest 
insidious disturbances of action should afterwards arise and 
proceed in some of the viscera, especially in the lungs. 
So many remarks having already been made on other local 
irritations which may occasion phthisis, it were needless 
to resume them here ; but I cannot refrain from again 
pointedly observing, that when those irritations exist in the 
digestive organs, the Harrowgate sulphureous water will, 
upon the whole, be found one of the best preventives. 

It was before noticed, that two circumstances are neces- 
sary for the production of the true phthisis : first, a predis- 
position in the lungs to the tubercular action, and secondly, 
the concurrence of an occasional cause to excite that ac- 
tion. The mere removal of the occasional or exciting 
causes of pulmonary consumption, has often been mistaken 
for the cure of that disease. Were I to enumerate, as di- 
rect recoveries from consumption, the instances in which 
it has been averted by removing the exciting causes, my 
success would seem great ; and yet, even in the incipient 
phthisis, I have not often succeeded in arresting its progress 
when the true tubercular action has been developed. If 
this statement shows how difficult it is to cure phthisis, 
when once it has taken root and begun to spread in the 
lungs, yet it also proves that threatened attacks of this for- 
midable malady may frequently be warded off by opportune 
care and proper measures. If we examine into the histo- 
ry of those causes which come before us, we shall often 
find, that the symptoms of phthisis had been preceded by 
those of some local irritation, or by indications of a break- 
ing up in the general health from the causes already speci- 



PULMONARY CONSUMPTION. 145 

fled. Now when phthisis is preceded by either of these 
states, its prevention is generally within the power of phys- 
ic, provided advice be early obtained ; but it too frequently 
happens, from delay on the part of patients, that the struc- 
ture of the lungs is disorganized when the practitioner is 
first consulted, and unfortunately all that is left for him to 
perform, is to palliate the prominent symptoms. It is sur- 
prising how careless patients are about themselves in the 
commencement of those chronic diseases, under which they 
are enabled to perform their ordinary offices ; and so long 
as they can walk about with tolerable ease, they flatter 
themselves that all is safe, when the complaint is day after 
day undermining their very vitals. No cough should be 
allowed to exist without attracting attention from the first, 
but especially if it be accounted slight or trifling by the pa- 
tient ; for that is frequently the short tickling cough which 
ushers in the assemblage of symptoms, by which consump- 
tion of the lungs is finally excited. 

When called to any case which has the character of a 
threatened or of an incipient phthisis, the practitioner must 
minutely inquire into its real nature, that he may ascertain 
whether or not it be connected with any local irritation in- 
side or outside of the chest, or with any depraved state of 
the general system. If such a local irritation, or such a 
depraved state of the general system actually exist, the 
chance of recovery is the greater ; for if either can be re- 
moved, by the means intimated, the pectoral symptoms 
may disappear, provided they depend upon a sympathetic 
disorder of action, and not upon derangement of structure. 
On the contrary, should the phthisical signs be unconnected 
with morbid conditions of this nature, perhaps the meas- 
ures upon which most confidence is to be placed, in the 
present state of our knowledge, are those which act direct- 
ly or indirectly on the skin, at least this is the result of my 
own observation. But it may first be naturally inquired, 
what is the power of blood-letting in the primary stages, as 
it is now becoming so favourite a remedy ? Celsus advises 
venesection, Pringle does the same, and other authors of 
note as well among the ancient as the modern : but I nev- 
ertheless suspect, that it will rarely of itself stop the ap- 
proach or advancement of phthisis, except when chronic 
infiammatioa of the pleura, of the trachea, or of other 

19* 



146 PULMONARY CONSUMPTION. 

parts is operating as an excitant of the latter in habits he- 
reditarily predisposed. In some cases of apparent genuine 
phthisis I have ordered repeated full bleedings from the be- 
ginning, until it would have been temerity to proceed fur- 
ther : yet the disease passed on, and the blood drawn gen- 
erally exhibited the buffy coat to the final operation. From 
this last mentioned circumstance some might contend, that 
the venesection should still have been boldly ventured on, 
as the blood so evidently showed inflammation. But in 
reply to this remark it may be urged, and justly too, that 
the buffy coat may be both occasioned and maintained by 
repeated abstractions of blood ; for more or less re-action 
of the heart and arteries, by which the buffy coat is pro- 
duced, always follows blood-letting when carried beyond a 
certain point, and this is particularly the case in the irri- 
table subjects, of a phthisical tendency. Upon this prin- 
ciple, therefore, the very measure with which we so often 
subdue inflammation, may be made the cause of producing 
it in certain persons, and in certain diseases : and however 
boldly and laudably we use it in intense inflammations or 
congestions, it requires a more deliberate and wary em- 
ployment in complaints of a chronic character. Most cer- 
tainly I have seen small or moderate bleedings of benefit 
in incipient phthisis, when followed by blistering, but wher- 
ever there is a great constitutional delicacy, we must be 
cautious even in having recourse to them ; and at all times 
when we determine on venesection in phthisis, we must en- 
deavour so to regulate it as not to make it the occasion of 
an increase of that re-action which it is designed to mod- 
erate. In the true tubercular phthisis, it is not a simple 
but a complicated irritation which most frequently exists in 
the lungs even in the commencement; an increased fulness 
of the capillaries either producing or exciting tubercles, 
and the tubercles themselves re-acting upon and irritating 
those portions of the lungs in which they are imbedded. 
Very copious or very repeated venesection only tends to 
render the whole capillary system of vessels more irrita- 
ble : from reason alone, therefore, one would conclude, 
that they would not be serviceable in phthisis ; and my own 
experience fully bears me out in affirming, that this is actu- 
ally the fact, small local or cautious general bleedings, so 
far as I have observed, being preferable to large ones. The 



PULMONARY CONSUMPTION. 14? 

lancet is perhaps only admissible in the earlier periods of 
those cases attended with topical fulness, and a marked 
constitutional excitement. However undeniable it may be, 
that phthisis is an excitive or an inflammatory disease, yet 
it seems probable, that the concomitant excitement or in- 
flammation is of a specific nature ; at all events, neither the 
one nor the other is within the common control of those 
agencies which so successfully impede the ordinary excite- 
ment and inflammation of febrile diseases. But as vene- 
section is a measure of such great importance, and as 
men of approved talents have spoken favourable of its de- 
cisive use in an unmixed phthisis, it would ill become me 
to disregard their authority ; and therefore it has been my 
wish simply to state the results of my own observation in 
regard to it, that the consideration of it may still remain 
open to fair inquiry. 

As I conceive, in a pure and incipient phthisis, that the 
most beneficial measures operate through the medium of 
the skin, it may not now be amiss to say a few words re- 
specting those measures. The best thing that can be done 
for one in whom pulmonary consumption is suspected, or 
actually existent in an incipient state, is to send him imme^ 
diately to a warm climate ; and the voyage to the place of 
his destination should be made rather long than short, as 
sailing upon the sea is very useful on many occasions. 
When physicians are called to a threatened or an incipient 
case of genuine phthisis, they are often anxious to keep the 
patient under their own eye, with the hope that they may 
be able to prevent or to stay the disease ; and thus from the 
best motives, day is allowed to steal over day, week over 
week, and month over month, until at length suppuration 
makes its fatal approaches, and until almost every chance 
of recovery is at an end. A change of climate or a sea voy- 
age at such a time can effect nothing ; and removing pa- 
tients from home then, is only to deprive them of those 
comforts which tend to mitigate their last sufferings. It is 
always a great and often a mortal error to protract a sea 
voyage, and a change to a warm climate, in an approach- 
ing, or incipient consumption. When the voyage is deter- 
mined on, and even when it is undertaken early, the patient 
must cover the surface with flannel or fleecy hosiery, so 
long as he shall remain in a cold or changeful atmosphere ; 



148 PULMONARY CONSUMPTION. 

and even when in a warm climate, he must still be attentive 
to the state of the skin, and be mindful to avoid being chill- 
ed by night air or by damp linen next the surface. 

In the summer of 1816, I was consulted for a young gen- 
tleman, in whose welfare I felt most deeply interested. 
While with his tutor in the South of England, he was attack- 
ed by haemoptoe, attended with a short tickling coug]h. His 
friends being naturally alarmed at the symptoms, he was 
removed, and placed under my care. On first seeing him, 
I was much struck with the change in his appearance, and 
no case could better exemplify than his that alteration in 
the state of the skin, which has been so pointedly noticed. 
In the preceding year he was ruddy and stout for his age 
and height; but his complexion was now of a sickly pale- 
ness, interspersed with some irregular streaks of red, and 
he, was shrunk in his flesh. The hands and the rest of the 
surface were blanched to what they had formerly been ; 
and his hair, which was peculiarly bright in health, now had 
a dirty appearance, and seemed in many parts to be split 
at the ends. His eyes had acquired a sort of pearly white- 
ness. At intervals of about ten or twelve minutes, a mo- 
mentary flush of red was spread over one or both of his 
cheeks, and then it left that remarkable pallidity to which I 
formerly alluded. His cough was of that short tickling de- 
scription, which commonly marks the invasion of the true 
phthisis ; and his circulation was in so very excitable a state, 
that the least exertion quickened it many beats in the min- 
ute. Though a little more capricious than usual, his appe- 
tite on the whole remained good ; and on examination I 
found the alvine evacuations healthy. His tongue was fur- 
red a little and whitish at the root, but smoother and red- 
der towards the end than natural. On a deep inspiration 
he felt some uneasiness within the chest, and generally 
coughed - x and added to these symptoms, he had some degree 
of fever at nights with a tendency to morning perspirations. 
This appeared to me to be a genuine threatening of phthis- 
is, for no common local irritation could any where be de- 
tected, and nothing had occurred to deprave the general 
habit ; and yet in this case there was an anxiety expressed 
about the nature and tendency of his complaints by the pa- 
tient, which is not common in such an affection. The con- 
course of symptoms, however, alarmed me exceedingly, and 



PULMONARY CONSUMPTION. 149 

I requested his friends to take him to the South of France 
without loss of time. Mean while I directed him to clothe 
himself rather more warmly, to regulate the temperature of 
his sitting and bed room, to live chiefly upon a milk diet, 
and to ride out occasionally when the weather was warm 
and temperate. On account of the excitable state of the 
circulation, I did not order blisters or any other irritants to 
the chest, and the emaciation and weakness deterred me 
from the use of the lancet, or even of local blood-letting. 
The compound rhubarb pill was all the medicine which 
was ordered, and of this he took one or two occasionally 
when the excreta did not seem proportionate to the ingesta. 
Under this mild plan, however, he somewhat improved un- 
til the preparations were completed for removing him 
abroad ; and he afterwards bore the voyage by sea, and the 
travelling by land, better than could have been expected, 
and I have had reports of the continued improvement of 
his health. This case may show how much may be done 
by a seasonable removal into a warm climate ; and whenev- 
er the circumstances of the patient can admit of it, I must 
once more repeat, that it ought to be undertaken without 
delay. 

But as this measure is only fitted for persons of a certain 
rank, it may be demanded, what is to be done for those who 
cannot go abroad ? In several instances 1 have advised 
such patients, threatened with consumption, to take a few 
voyages in vessels that traded from one part of England to 
another ;. and in the spring, summer, or autumn, they often 
answered an excellent purpose, especially when the weath- 
er was fine. But I have always strongly enforced the ne- 
cessity of very warm clothing while they were sailing from 
place to place ; and pointed out to them the example of 
the sailors of some of the northern ports, who mostly wear 
flannel next the skin when at sea, and besides this, protect 
themselves still more by woollen jackets, trowsers, and 
coats. If patients be regardless of their clothing when at 
sea, they are very apt to catch cold, and may thereby coun- 
teract the good of the voyage ; whereas if the whole sur- 
face be defended properly with flannel or fleecy hosiery, 
they place themselves under the most favourable circum- 
stances. 

The beneficial effect of a sea-voyage and of a warm cli- 



150 PULMONARY CONSUMPTION. 

mate, in the threatening or first invasion of phthisis, is chief- 
ly referrible to the influence which they have upon the sur- 
face \ the nausea or sickness commonly attendant on the 
first, and the high and genial temperature of the last, alike 
determining the blood to the skin, A new impression is 
therefore at once instituted and maintained, and that on so 
large an extent, and on so sympathetic a part of the body, 
as sometimes partly or wholly to arrest the disorder in the 
capillaries of the lungs. And when we are not able to com- 
mand either of these powerful auxiliaries for the subjects 
of an incipient phthisis, we can find substitutes, the opera- 
tion of which is somewhat analogous to theirs, though far 
less efficacious. Accordingly a regulated temperature, and 
the exhibition of tartarized antimony to excite nausea or 
vomiting, are sometimes combinedly advantageous in impe- 
ding or alleviating phthisical attacks ; and I suspect, that if 
they were more early and perseveringly employed together, 
our success might be greater, where patients cannot be sent 
abroad. The efficacy, however, of sailing upon the sea 
cannot always be referrible to nausea and its sympathetic 
effects, for I have known a voyage useful where no nausea 
was excited. In fact, sailing alone seems to increase the 
secretion of the skin, as we may observe in sailors, while at 
the same time it apparently communicates an invigorating 
influence ; and to one or both of these perhaps its salutary 
power may be partly attributed in pulmonary affections. 

In speaking of phthisis pulmonum, Heberden acknowledg- 
es, that patients bore sailing upon the sea well, even when 
they spit up great quantities of blood ; and he moreover 
adds, that the hsemoptoe has not been in the least aggrava- 
ted by a voyage of six weeks, though excessive vomiting oc- 
curred during the whole of that period. If we permitted 
ourselves to reason, a priori, on matters which involve 
health and life, we might probably conclude, that emetics 
must necessarily be prejudicial in spitting of blood : yet I 
have found them extremely serviceable in that species of 
haemoptoe which takes place in habits apparently phthisic- 
al ; and agree with Dr. Bryan Robinson, and with Dr. 
George Rees, that they are, generally, preferable to the use 
of the lancet in such cases.* Not that I mean to imply by 

* Upon this point the reader may consult with advantage A Prac- 
tical Treatise on Hsemoptoe, or Spitting of Blood. By George Rees, 



PULMONARY CONSUMPTION. 151 

insinuation, that blood-letting is never needed in the haemo- 
ptoe of these habits, but some remarkably impressive facts 
have inclined me to believe, that profuse bleedings are al- 
ways hazardous : and even moderate ones are perhaps in 
general better omitted, unless there be the most distinct ev- 
idence of topical fulness with general excitement, and then 
cautious venesection is necessary. It is an excellent re- 
mark of Heberden,* particularly when applied to phthisic- 
al constitutions, that where an hemorrhage proceeds from 
the rupture of some very large vein or artery, venesection 
will not restrain it, and that when it proceeds from some 
small one it will stop without the help of the lancet. When 
spitting of blood is the result of an affection of the trachea 
or bronchia, emetics are not inadmissible ; but when haemop- 
toe is connected with obstruction in the liver, purgatives 
are then decidedly indicated, and, so far as I have remark- 
ed, emetics ought not to be exhibited. Neither can emet- 
ics be given to pregnant women attacked with haemoptoe, 
without the hazard of causing an abortion, and on this ac- 
count it is most prudent to avoid their administration. 
When spitting of blood does take place in pregnant women, 
it is mostly connected with hepatic disease, and with a gen- 
eral excitement of the arterial system. In such examples, 
therefore, moderate venesection is generally requisite and 
useful, particularly when followed by purgatives ; and where 
the liver is manifestly affected, after a few doses of calomel, 
the almost daily exhibition of the Harrogate sulphureous 
water, with some aperient pill, will frequently be very ad- 
vantageous. But as scybala are apt to be retained in the 
colon, castor oil ought occasionally to be administered, as 
it will more effectually and mildly dislodge them than any 
other medicine. When the skin is hot and dry in an has- 
moptoe, cool air may be liberally admitted, and cool drinks 
given -, but when the skin is cold, this practice requires 
caution, as it may tend to excite phthisis in the peculiar 
habit. In three or four cases of uterine hemorrhage, I have 
seen phthisical symptoms apparently called into action by 
the too free and long continued use of cold applications. 

M. D. Member of the College of Physicians, &c. London : printed 
and published by M. Allen. 1813. 

* On opening a Vein in Haemorrhages, Read at the College of Phy- 
sicians, December 11, 1771 



152 PULMONARY CONSUMPTION. 

Whenever the practitioner is compelled to recur to these 
applications, he should afterwards pay the strictest atten- 
tion to his patient; for from the combined influence of the 
cold, and the shock which the system sustains by large loss- 
es of blood, acute or chronic diseases often supervene, 
when nature attempts to rally by means of an arterial re- 
action. If there be much nervous irritation in any case of 
boemoptoe, opium is frequently of great use, but especially 
when the loss of blood has been large ; and my general ex- 
perience of the efficacy of this medicine in copious erup- 
tions of blood fully confirms the commendations which Dr. 
Stewart has bestowed upon it in uterine hemorrhages. 
When the system has been excessively exhaused by loss of 
blood, an extreme nervous agitation arises, which not only 
re-acts upon the heart and arteries, but which may destroy 
life from its' mere continuance. This agitation is often so 
surprisingly calmed by opium, that I have seen patients, 
seemingly in the jaws of death, saved by its administration. 

But in regard to the skin, my attention was first drawn to 
its consideration from observing the great changes which it 
underwent in its colour and functions on the approach or 
invasion of pulmonary consumption; and its pathological 
influence became still more interestingly set before me, 
when I saw some patients fall into that disease shortly after 
the disappearance of cutaneous eruptions, and others great- 
ly relieved by the accidental or spontaneous occurrence of 
such affections at an early stage. It naturally, therefore, 
became a question with me, whether any thing could be 
done for the prevention or cure of phthisis, by attending 
more closely to the state of the skin than had hitherto been 
done. What relates to the prevention on this head, has al- 
ready been noticed, and it only now remains to prosecute 
the hints which have just been thrown out respecting the 
treatment, through the medium of the surface of the body. 

If medical men were asked, what expedients, upon the 
whole, are really useful in checking or relieving the symp- 
toms of an incipient phthisis, a large majority would proba- 
bly be in favour of blisters ; for concerning their agency less 
discrepancy of opinion perhaps exists, than upon that of most 
other means daily prescribed. In modern times the use of 
blisters has almost superseded that of issues, which were so 
famous in the ancient world, and which maintained a char- 



PULMONARY CONSUMPTION* 153 

acter for centuries ; and though the former are decidedly 
preferable to the latter in many diseases, yet perhaps their 
application in chronic ones is too much limited to a particu- 
lar spot. The ancients applied their issues to various parts 
of the skin, the moderns generally apply their blisters to one 
part. But, if my experience be allowed of any weight, we 
should resume the method of the ancients in many chronic 
diseases of the internal organs. When we apply leeches to 
the external vicinity of an inflamed viscus, we suppose that 
their whole efficacy depends upon their relieving the fulness 
of the internal vessels, from their inosculation with those 
on the surface : yet only a part of their efficacy is really at- 
tributable to this effect, for I have found from experiments, 
the results of which shall afterwards be reported, that their 
influence on the general circulation is infinitely greater than 
has usually been imagined. Besides this, attentive observ- 
ation will soon convince any one, that between the whole 
capillary system of vessels there is a sort of specific sympa- 
thy : so that influencing their action in one part of the body, 
frequently produces striking effects in that of other parts ; 
and the more this circle of sympathies in the capillary ves- 
sels is investigated, the more important it will be found in , 
pathology and practice. Now the efficacy of blisters is not 
altogether local, as has generally been imagined. No doubt 
they often operate a change of condition in the part beneath' 
the place of their application, but independent of this and 
also of the local inflammation which they produce, they af- 
fect the constitution at large ; and it is partly by this their 
general influence, that they powerfully contribute to destroy 
the mixed associations of many maladies. No local affec- 
tion of consequence can exist without implicating the whole 
system in disorder ; and, on the contrary, no general shock 
can be long sustained without implicating particular parts. 
Most of the measures which we employ act generally as well 
as locally ; for there is an indivisibility of the vital as of the 
mental principle. We do not so much cure diseases by 
directly removing them, as by instituting states incompatible 
with the existence of those diseases ; and in considering the 
treatment of almost every complaint, it should be our object 
to discover, what are those remedies which create a local 
and general change inconsistent with that of the existing 
disease. It has long since struck me, forcibly struck me, 

20* 



154 PULMONARY CONSUMPTION. 

that a most important improvement might be effected in the 
treatment of consumption by ascertaining the powers of 
those agents which act on the skin. But having hitherto 
not had the good fortune to be attached to an hospital where 
I could have a sufficient number of incipient cases constant- 
ly under my inspection, my inquiries have been retarded ; 
and therefore all that 1 can do at present is, earnestly and 
anxiously to call the attention of the faculty to the subject, 
by limited facts and suggestions. In some cases of threat- 
ened phthisis, I have seen very great benefit from almost 
daily sponging the skin with water and vinegar, and have 
sometimes added a little salt with apparent advantage. The 
spongings not only lessened the disposition to fever, but also 
greatly refreshed the patient, increased the appetite, and 
lessened the cough ; while they also seemed to communi- 
cate a tone to the surface, which enabled it to bear the in- 
fluence of the atmosphere better than before. 

Consumption has most frequently been presented to me 
in a confirmed state, when little was to be expected from any 
measures ; but even then I have seen much temporary re- 
lief of symptoms from very small blisters to the chest and 
other parts of the body, either applied at the same time, or 
in quick succession. In other instances of this kind, crops 
of pimples in different parts of the skin have appeared to be 
beneficial ; and the best mode of inducing them is by an 
unguent, made of the tartar emetic, camphor, and common 
white ointment, in the proportion of one drachm of the first 
and of the second ingredient, to an ounce of the third. A 
little of this compound well rubbed upon any part of the 
skin will soon bring out a crop of pimples ; and where it is 
found to fail, the proportion of tartar emetic must be increas- 
ed until it answers the purpose intended. Yet in the last 
stage of consumption, there are some cases where these and 
similar irritants procure no alleviation, nay, where they 
seem to do harm by increasing the fever ; and in examples 
of this nature, the only measares in common use, which can 
be of much service through the medium of the skin, are a 
regulated temperature, and the occasional employment of 
the tepid bath, or of the tepid affusions. But as the last 
stage of consumption, with all its appalling concomitants, is 
merely the product of preceding disorder, we must rather 
endeavour to look to this disorder, and to inquire how far it 



PULMONARY CONSUMPTION. 155 

can be affected by powers which operate upon or through 
the skin. Very small blisters applied to different parts of 
the integuments of the chest, aided by issues or pimples in 
the upper and lower extremities, have seemed to arrest the 
progress of some incipient cases of consumption ; but then 
their operation was assisted by one or two small bleedings, 
by occasional antimonials, by a regulated temperature, by 
a light diet, and by the warm bath. In other instances, how- 
ever, these very measures failed, even when applied under 
circumstances apparently as favourable as in those where 
they had succeeded. These facts would perhaps authorize 
the conlusion, that what is called the tubercular consumption 
is a specific affection, under which some varieties occur ; 
for if this were not the case, why should the same measures 
succeed in some, and utterly fail in others ? The truth is, 
that the true tubercular phthisis does comprehend varieties, 
which have not yet been discriminated : and of this I have 
been convinced, from the various appearances of the pus, 
and from the different characters of the tubercles found in 
the lungs, as well as from the circumstances above noticed. 
If the nature and pathognomonic signs of these varieties 
could be ascertained, it would be an important step in the 
pathology of phthisis, and might perhaps finally enable us 
to improve the treatment. 

The trials, however, which I have made of counter-irrita- 
tion on the skin in incipient phthisis would not authorize me 
to draw a general conclusion as to their effect : in the first 
place they have not been sufficiently numerous, and in the 
next they have rarely been carried so far as I could have 
wished, on account of the prejudices of patients or their 
friends. But it would give me infinite pleasure should this 
practice, in connection with other measures, be found effi- 
cient in certain cases ; and even if it were thus efficient, 
still we can hardly expect that our success from it in the 
main should be so considerable as in those diseases of an 
ordinary character, the varieties of which have been more 
correctly ascertained. In the treatment of most diseases, 
success is rather probable than certain. " When an exper- 
iment has succeeded in several trials, and the circumstance* 
have been marked with care, there is a self-evident proba- 
bility of its succeeding in a new trial ; but there is no cer- 
tainty. The probability, in some cases, is much greater 



156 PULMONARY CONSUMPTION. 

than in others ; because, in some cases, it is much easier to 
observe all the circumstances that may have influence upon 
the event than in others. And it is possible, that, after 
many experiments made with care, our expectations may 
be frustrated in a succeeding one, by the variation of some 
circumstance that has not been, or perhaps could not be 
observed."* What might be the effect of the revival of the 
practice of iEtius, I cannot pretend to determine : but I 
have long wished to try either it, or something like it, in 
genuine cases of incipient phthisis ; and were 1 myself at- 
tacked by that disease, would not hesitate to adopt some 
similar method, most probably after the use of moderate 
depletion, and antimonials. 

Some time ago a poor woman applied to me for advice, 
who seemed to be hurrying towards the grave, from the 
force of a recent but rapid consumption. She happened to 
be attacked by an eruption resembling the common itch, 
and the alleviation which it gave to the chest was so strik- 
ing, that I resolved to let it spread on the skin. The 
phthisical symptoms wholly disappeared under its progress, 
and it was, after some weeks' duration, cured by the sulphur 
ointment ; but by way of guarding against consequences, I 
ordered a seton to be made in one of the sides, and an issue 
in one of the arms. In the case of another female, who 
was nearly in the same state, the cough and fever gradually 
abated on the coming out and continuance of a spontaneous 
rash, and she recovered apparently from its influence alone. 
One patient was always relieved of a constitutional sort of 
cough, when pimples came freely out upon her face ; but 
they disappeared entirely under the use of a lotion, and 
she shortly afterwards fell a victim to true consumption of 
the lungs. These and similar facts which I could* mention 
have made a deep, an indelible impression on my mind ; 
and if my desire be great to make their results recollected 
by others, the vital importance of the subject must plead 
my excuse. 

On a first view it might be supposed that such extreme 
counter-irritation as iEtius has advised must necessarily be 
injurious. It might and probably would be so in a condi- 

* Essays on the Intellectual Powers of Man. By Thomas Reid, D. 
D. %c. See p. 559. Edinburgh ; printed for John Bell. 1 785, 



PULMONARY CONSUMPTION. 157 

lion of health. The case, however, is widely different 
when the body decidedly labours under disease ; for coun- 
ter-irritations are then often well borne, which would have 
been intolerable and injurious in a sound state. Apply a 
rapid succession of blisters to a strumous habit in whom no 
disease apparently exists, and you will excite the system 
into great disorder ; but let another and a similar habit ac- 
tually labour under disease, say of some of the joints, and 
you may apply blister after blister not only without injury, 
but with positive advantage. We are far too apt to reason 
about the-operation of remedies in disease from what we 
have observed of their effect in health ; yet we must always 
take into account the condition of the body at the time of 
administering our measures, otherwise we shall be liable to 
the most serious mistakes. The common mode of making 
issues has appeared to me extremely defective ; for after 
the first irritation subsides they are generally allowed to 
exist a long time simply as drains, which are of little or no 
use. To be really efficacious, issues should be often re- 
newed, that there may be a sort of perpetuity of irritation. 
In several scrofulous affections of the joints, I have seen 
more benefit from blisters than from isssues, especially 
when the former have been managed in a particular way. 
My plan now is simply this. When the blisters are taken 
off, the part is dressed for the first time with any of the com- 
mon cerates ; but on the second dressing, the whole of the 
blistered cuticle is torn off, and the raw surface daily dres- 
sed with the ordinary blistering ointment, until a considera- 
ble slough be formed. The slough is afterwards allowed 
to heal, and then the same process instituted again, so long 
as the disease shall remain unsubdued. The irritation of 
this treatment is frequently extremely great, but I have seen 
it remove scrofulous diseases, where every other expedient 
had failed. Whether it be applicable to any cases of con- 
sumption, which after all are really scrofulous, must be left 
for others to decide. But from the evidence before addu- 
ced, it is highly probable, that counter-irritation of the skin 
is not equally applicable to all cases ; for even in regard to 
blisters, we see some patients bear them well, compared 
with others. One large blister often exhausts a great deal 
more than several small ones ; and many patients are bene- 
fited from the latter, who are hurt from the former. In 



158 PULMONARY CONSUMPTION. 

phthisis, too, some patients are exceedingly oppressed, and 
others exceedingly relieved in their breathing, by an eleva- 
ted temperature ; and this seems to depend upon some dif- 
ference in the state or organization of the skin. Those 
who are relieved by an elevated temperature perspire equa- 
bly over the surface ; whereas in those who are oppressed, 
the skin hecomes hot or dry, or there is only a very partial 
perspiration, and we may perceive their chests heave with a 
preternatural effort. Similar effects are produced by an 
elevated temperature in healthy persons, those who per- 
spire freely bearing it well, and those who do not being 
greatly disordered in the respiration : and we may even 
observe in the lower animals, that those which perspire the 
least, pant and labour the most in the lungs from heat. But 
it is time to conclude my remarks with respect to the influ- 
ence df the skin in cases of consumption. 

In the preceding hints the tepid bath has been mentioned 
as a proper expedient for phthisis. When used in the 
morning or evening, it often lessens the hectic in incipient 
and sometimes even in confirmed cases. But the tempera- 
ture of it should rarely be beyond 94° of Fahrenheit, the 
patient should seldom remain in it longer than a quarter of 
an hour, his skin should be well dried and rubbed with flan- 
nel after he comes out of it, and he ought to rest upon a bed 
or sofa for some time, lightly covered. If these precautions 
be disregarded, the tepid bath will frequently do harm in- 
stead of good ; and indeed when they are observed, it pro- 
duces exhaustion or irritation in some — so various are the 
effects of the same measure in different subjects. When 
there has been any considerable haemoptoe, I have never 
ventured upon the use of the tepid bath ; but in many in- 
stances, where the expectoration has been merely streaked 
with blood, it has been attended with advantage. Where 
spitting of blood is connected with high vascular excitement,' 
one would naturally suppose the tepid bath to be inadmissi- 
ble ; but where, on the contrary, it appears to be connect- 
ed only with irritation and constitutional delicacy, there 
need be no dread of its employment, provided the tempera- 
ture be cautiously regulated. One of the ablest men and 
ablest physicians of this country, I know to be partial to the 
use of the tepid bath in those passive hemorrhages of the 
uterus, which happens in weak and delicate habits ; and if 



PULMONARY CONSUMPTION. 159 

it can be safely and advantageously employed under such 
circumstances, perhaps it might be beneficially applied to 
similar effusions of blood from other organs. Local distur- 
bed action of the arteries, or local fulness of the veins, fre- 
quently exists in combination with great constitutional de- 
bility : and hence we frequently see the most delicate wo- 
men very liable to copious menstrual orlochial discharges. 
When great constitutional debility exists, two states may be 
coeval, as its concomitants or its consequents : the first a 
disturbance of action in the capillary arteries, the second a 
fulness of the venous system. It necessarily follows that 
when the energy of the heart and arteries is much diminish- 
ed, that they cannot maintain the natural current of arterial 
blood, and of course a proportionate accumulation takes 
place in the veins ; and this venous accumulation appears 
to load and stimulate the capillaries of the arterial system, 
by retarding the return of the blood through them. These 
remarks render it probable, that the tepid bath might actu- 
ally relieve many cases of what are called passive hemorr- 
hages, by equalizing the circulation ; for it not only brings a 
flow of blood from the interior towards the surface, but it 
communicates an equable tone to the heart and arteries, 
thereby enabling them to resume their wonted offices. — 
These suggestions, however, are merely thrown out for the 
aonsideration of others ; and I wish it to be distinctly under- 
stood, that they are suggestions only, and not positive re- 
commendations. In another place I shall mention the effi- 
cacy of the tepid bath, containing the sulphuretted hydrogen 
gas, in various chronic diseases ; and shall adduce some 
<*facts which will render it highly probable, that the internal 
use of that air might be successfully applied to certain cases 
of phthisis. In the mean time, I shall close my remarks on 
the skin for the present, with some allusions to frictions, 
medicines, and regimen. 

In the time of Celsus, the iatroalipta, or anointer, follow- 
ed his business as a distinct branch of the profession :* 
and we well know, that both before and after, frictions and 
anointing were frequently recommended by some of the 
most celebrated physicians of the ancient world. It were 



* Sanus homo, qui et bene valet, et suae spontis est, nullis obligare s# 
legibus debet, acneque medico, neque iatroaiipta egere. Cels. lib. i 



160 PULMONARY CONSUMPTION. 

of little use to inquire, why these methods should have fallen 
into neglect and disrepute in modern times ; but that they 
might be revived with benefit to the community in many 
diseases, is a proposition highly probable, if not quite 
certain. Beyond the. mere rubbing of the skin by dry and 
warm flannels, I have not ventured in phthisis after the em- 
ployment of the bath ; but it is evident, that Celsus thought 
frictions applicable in some cases, and his authority is de- 
serving of great respect. There is a principle in human 
nature which makes us shrink from present pain, even some* 
times to the disregard of the ultimate good which that pain 
might produce ; and hence in the application of blisters, in 
the making of issues, and especially in incisions by the 
knife, we often find a great reluctance on the part of pa- 
tients to comply with our wishes. It is the operation of 
this principle, frequently strongest in uncultivated minds, 
that has chiefly prevented me from having made fair trials 
of counter-irritation by the skin in incipient consumption : 
but as friction is a much easier way of inducing an univer- 
sal impression upon the surface, it might surely be worthy 
of some attention to ascertain its effects in this disease. 
Indeed it is my design to do so, when favourable occasions 
shall occur: but I could wish that the subject should claim 
the investigation of others. From Galen it would appear 
that the ancients anointed the skin, without frictions, after 
the warm bath, to prevent copious perspiration ; and even 
this procedure, simple as it is, might be of some utility, 
where we wish to procure the soothing without the sudori- 
fic effects of the bath. Wherever the use of the tepid bath 
might occasion more fatigue than the patient could conven- 
iently bear, the tepid affusion or ablution may be substitu- 
ted when the hectic runs high. 

It will have been perceived, that I have not noticed any 
of those medicines which are usually recommended for 
phthisis. The fact is, that those medicines have deceived 
me so often, as to make me doubt, nay to deny the utility 
of the most of them. It is a little singular, that we have 
an abundance of reputed remedials for those diseases of an 
opposite class. No great discovery was ever made in 
science but what has been simple : so simple, indeed, that 
men have wondered it should not have been made before. 
And if a specific should be found for consumption, it too 



PULMONARY CONSUMPTION. 161 

will most probably be simple. We have surely had expe- 
rience enough to convince us of the futility of confidently 
trusting to any of those medicines which have hitherto been 
recommended ; and we should not remain stationary in our 
art by being satisfied with them, but endeavour to explore 
the virtues of things which have not yet been tried. Di- 
gitalis is an excellent drug, in common inflammations of the 
chest, and in some dropsies ; but experience does not au- 
thorize me to say, that it is certainly useful either in an in- 
cipient, or in a confirmed phthisis, its effects being fairly 
weighed. The immediate relief which it sometimes gives, 
by arresting the pulse, and by exciting nausea and diuresis, 
is in general completely counteracted by the constitutional 
shock and nervous irritation which it communicates ; and 
as for its influence in a confirmed phthisis, however it may 
alleviate the cough for a time, it will always hasten death, 
by undermining the little strength which remains in the 
shattered system. When it was clearly discovered that di- 
gitalis greatly reduced the force and the frequency of the 
circulation, it was a very natural supposition, that it might 
be of benefit in both the stages of phthisis — in the incipi- 
ent, by arresting the excitive action which produced or ag- 
gravated the tubercles — and in the confirmed, by allowing 
the lungs so much comparative rest, through its effect on 
the pulse, as to bring the sanative powers of nature fairly 
into play. This supposition, too, was the more specious, 
when digitalis actually appeared to exert an influence over 
the phenomena of common inflammation. But impartial ex- 
perience has added another memorable proof, that the an- 
ticipations of theory are far more frequently disappointed 
than realized. When digitalis is carried so far as decided- 
ly to weaken the heart, it seems to occasion great venous 
congestions of the brain and other vital organs, in combi- 
nation with a peculiar collapse of the whole system. The 
consequence sometimes is, especially if he had been pre- 
viously infirm, that the patient's life may be immediately 
hazarded ; and if he should recover from the congestions 
and collapse, an excessive and tremulous sort of re-action 
succeeds, which makes his condition often worse than be- 
fore he took the digitalis. The best way to remove the 
congestions and collapse produced by digitalis, is to give 
the patient moderate and repeated doses of opium, a little 
21* 



162 PULMONARY CONSUMPTION. 

brandy or good wine, and light support. The congestions, 
I have said before, are peculiar, inasmuch as they are at- 
tended by an universal collapse from the first, and in all 
cases of congestion combined with this collapse, opium will 
be found an excellent remedy. Digitalis has, through the 
heart, an effect on the brain, different from that of opium. 
The first produces venous fulness, the last arterial excite- 
ment ; and it is on this difference of action, that the opium 
counteracts the influence of digitalis. When venous con- 
gestion occurs from ordinary causes, and when it is con- 
nected merely with general oppression, small or moderate 
blood-letting is one of the best remedies ; but, on the con- 
trary, whenever venous congestion and universal collapse 
takes place at the same time, venesection would be highly 
dangerous, if not a mortal measure. In syncope from loss 
of blood, the venous system is in a state of congestion, and 
also in the collapse of approaching death ; but no practi- 
tioner would ever think of bleeding in either of these states, 
while he would not hesitate a moment to do so on the first 
attack of that species of apoplexy which depends upon ve- 
nous congestion. The ancients, from having found the ar- 
teries empty after death, concluded that all the blood was 
in the veins, during life; and we perhaps never weaken the 
action of the heart and arteries beyond a certain measure^, 
without causing a proportionate accumulation of blood in 
the veins, and thereby destroying the natural balance of 
the circulation. In every state of collapse connected with 
venous congestion, whether from loss of blood or any other 
cause, opium communicates an energy to the arterial sys- 
tem of the brain, which may often preserve life ; but if 
other organs beside the brain be congested, it ought to be 
combined with calomel, as the conjoint power of these two 
agents rouses the whole arterial circle into activity. If 
any medicine could be found, which reduced the pulse in 
phthisis, and neither caused immediate congestion with 
collapse, nor ultimate arterial re-action with nervous agi- 
tation, perhaps it might be of great utility. Thehepatized 
ammonia probably merits a trial, as Dr. Rollo found it re- 
duced the pulse so much in diabetes ; and if it should not 
answer, another might surely be found amongst some of 
our chemical combinations. But as for digitalis, it is prob- 
able that an increased fulness of the capillaries is not in- 
consistent with its sedative effects on the heart and larger 



PULMONARY CONSUMPTION. 163 

arteries : for when great venous congestions exist, nature 
often strives to re-act by the capillary vessels ; and hence 
a flow of urine and a moist skin not unfrequently attend the 
exhaustion produced by digitalis. Perhaps most of the 
good, without any of the bad effects of digitalis, may be 
procured from the cautious use of the tartarized antimony 
in threatened phthisis, where it may be expedient to lessen 
the force of the heart ; for by small and repeated doses of 
the latter the pulse may be powerfully controlled, and a 
state similar to the nausea of sea sickness induced, which 
is sometimes so exceedingly beneficial. The influence, 
however, of tartarized antimony and digitalis over the 
heart is different : the former occasions a small and rather 
quick pulse ; the latter a slow, irregular, and rather full 
pulse ; and yet in ordinary cases of inflammation, I have 
seen a similar result from these two agents over the topi- 
cal disease through the heart. In fact they both possess 
powers, but especially in inflammatory affections of the 
lungs and their appendages, which have not yet been right- 
ly estimated by the profession ; and digitalis in particular, 
has fallen into unmerited neglect in phlogistic diseases, 
merely because it has been found to fail in phthisis, which 
is a specific complaint. 

Whenever there is a tendency to phthisis, large quanti- 
ties of acids should be avoided ; for by disordering the di- 
gestive organs, they may indirectly prove exciting causes. 
It is notorious in certain ranks of society, that the daily use 
of acids will produce leanness. Hence young women who r 
have a disposition to grow fat, sometimes take them to 
counteract this, and often become chlorotic, but occasion- 
ally phthisical. The nitric and sulphuric* are the mineral 
acids which I have seen administered in incipient and con- 
firmed phthisis, but I have not known them useful, further 
than that the latter sometimes acts on the skin, and as for 
the citric acid it is merely grateful as a drink ; though an 
experienced physician lately told me that he had witnessed 
the most striking benefit from the internal use of vinegar in 
some cases of consumption. A blood-redness of the tongue 
is not an uncommon attendant on the hectic of genuine 
consumption. In many instances of common continued 

* The sulphuric acid which is commonly sold frequently contains a 
considerable portion of lead ; and therefore this medicine should not be 
prescribed by any practitioner, until he has ascertained its puritv 



164 PULMONARY CONSUMPTION. 

fever where a similar condition of the tongue existed, I have 
observed good effects from the muriatic acid, to the extent 
of two or three drachms, during twenty-four hours, largely 
diluted with water ; but I cannot say whether it might be 
beneficial or not in phthisis where this blood-red tongue is 
present ; and only mention the fact of its being so in cer- 
tain cases of continued fever, by way of pointing out an 
analogous symptom that may perhaps ultimately lead to a 
practical improvement. Perhaps my own experience of 
the acids ordinarily employed may have before too deci- 
dedly prejudiced me against agents of a similar denomina- 
tion ; and indeed we are much too prone in physic to class 
the effects of some medicines from their sensible properties, 
though those effects may be exceedingly different. 

Small and repeated doses of the sulphate of zinc have 
seemed to moderate the hectic in the last stage of consump- 
tion ; yet the best measures with which we are acquainted 
too often fail even to palliate the symptoms. Opium is the 
chief mean upon which we commonly rely, in this country, 
for alleviating the sufferings attendant upon the last stage of 
phthisis ; but we should be mindful not to give it in too 
large or too frequent doses, lest it check the expectoration, 
and oppress the lungs, through its operation on the brain. 
For several years past, the Italians have been in the habit 
of using the prussic acid as a palliative in consumption, and 
recently it has been given in France, where even more than 
palliative powers have been bestowed upon it. From a 
conversation which 1 lately had with a foreign physician of 
great discernment and candour, who has often seen it ex- 
hibited, it would appear that the prussic acid does possess 
as high a palliative effect as any medicine now in use ; for 
he informed me, that it lessened the irritation and cough, 
reduced the fever and pulse, and was very soothing to the 
feelings of the sick. Not more, I understand, that fifteen 
drops of this drug, as prepared by Scheele, can be adminis- 
tered with perfect safety in general throughout the day, 
and even this quantity cannot be safely given at once. A 
few drops only must be exhibited at first, and then it must 
be gradually increased, in divided doses, to the above 
amount, — such great care does this active substance require. 

The apparent benefit which I have seen to result from 
sudorifics and diuretics in some cases of threatened con- 
sumption, would alone seem to indicate the applicability of 



PULMONARY CONSUMPTION. 165 

medicines which act upon the kidneys and skin in certain 
examples ; but as my own experience is defective on this 
point, I recommend it to the notice of others, as well from 
practical as pathological considerations. Since the diet 
also affects the condition of the skin and kidneys, we want 
some information respecting its agency in incipient and 
confirmed consumption. It is well known, that the quan- 
tity and quality of the urine, and the appearance of the 
skin, can be materially influenced by diet among some of 
the lower animals, as experienced grooms are fully aware ; 
and, to pass over some familiar facts that might be adduced, 
it is but reasonable to conclude, from the common analo- 
gies of nature, that similar effects would occur in the human 
species, through the like means. Now as the skin and kid- 
neys both closely sympathize with the lungs, is it probable 
that the diseases of the latter might be benefited by certain 
articles of food which operate on the former ? Trifling as it 
may appear to some, this is nevertheless a subject worthy 
of investigation, not only as it regards phthisis, but other 
diseases of the internal organs. 

In a former page, a nutritious diet was recommended for 
those of a consumptive stock, and I must here re-assert, 
that it has in general appeared to me decidedly preferable 
to a spare one, as a preventive of this disease ; but though 
I have advised the moderate use of animal food, and even of 
mild ale, yet distilled spirits and wine should be avoided, 
as they are poisons to delicate habits. For more than 
twelve years, I have watched the repeated threatenings of 
phthisis in one constitutionally predisposed to it ; and the 
disease has hitherto been warded off by maintaining his 
strength with nutritious food, by defending the surface well 
with flannels, and by preserving the digestive organs in a 
proper state. Occasionally mild ale has been of great ser- 
vice to him ; and whenever his sleeps have been broken 
at nights, he has generally found advantage from a little an- 
imal food at breakfast. But at all times wine and spirits 
have been prejudicial to him, even when sparingly taken. 
Other instances of the same kind could be brought forward 
where a similar plan has had similar success. Although I 
am aware that variation of circumstances may require a 
variation of this plan, yet it may be safely affirmed, that few 
phthisically disposed persons bear a spare diet well, lor it 



166 PULMONARY CONSUMPTION. 

contributes to agitate the nervous and the vascular systems, 
The main consideration in respect to diet is, that it should 
support, without exciting the constitution ; and if this rule 
be attended to, it will be easy to select the articles of food 
suitable to different individuals tainted with the latent ten- 
dency to phthisis. But what may prevent a disease, often 
becomes improper when it has once been developed. Ac- 
cordingly, in an incipient consumption of the lungs, my ob- 
servation would lead me to conclude, that a milk and vege-t 
table diet is mostly superior to every other ; and indeed so 
general an agreement, as to this particular, among the an- 
cient and modern authors, could only have arisen from the 
conviction of experience. Informer ages the milk ofth6 
ass or goat was prescribed in Greece and Arabia, not be- 
cause the physicians preferred it to that of the cow, but be- 
cause the first was plentiful, and the last scarce in those 
countries.* We find, however, that this preference after- 
wards continued more or less among the faculty, even in 
places in which cows' milk abounded ; and though it is now 
disregarded by most of the practitioners of this country, it 
still exists in full force in the minds of the public, where 
medical prejudices always find a last asylum. Upon the 
whole, cows' milk is certainly the best. When it does not 
sit easy upon the stomach, a little arrow root or soda water 
may be added, or it may be boiled with coffee. In the last 
stage of consumption, those articles of food are the most 
suitable which tend to support the system under- suppura- 
tion, without augmenting the fever and cough : and when 
animal food and ale neither augment the cough nor the fe- 
ver, they may be safely and advantageously given at that 
time ; but when they do augment one or both of these symp- 
toms, they must be wholly withdrawn, and milk and vege- 
tables used as in the first stage. 

Sydenham has extolled exercise on horseback as an al- 
most certain specific for phthisis ; but though experience 
has proved the inefficiency of this, as of every other mean 
hitherto recommended, yet as a preventive and palliative, 
horse-exercise is deserving of particular attention. There 
is something peculiar in the effect of riding at an easy pace. 
It communicates a motion to almost all the viscera, and 

* See Blackmore's Treatise, p. 1 12, 1 13> 



PULMONARY CONSUMPTION. 167 

seems to invigorate the muscular fibre and whole frame; 
but its great superiority in disease over walking, which 
quickens the pulse much, seems to consist in keeping the 
heart at its usual rate of beating, while the rest of the sys- 
tem has all the advantages of exercise ; and hence its spe- 
cial adaptation to many chronic diseases, where there is 
that species of functional disorder present, which has a ten- 
dency ultimately to pass into structural derangement. Mo- 
derate exercise on horseback, therefore, should generally 
be recommended in fine weather for those who may have 
any disposition to phthisis, and it will even be found useful 
in the incipient state of that disease ; but the weakness of 
the last stage generally precludes its use, and then exercise 
in an open or covered carriage is much preferable, and it is 
remarkable how well many phthisical persons bear travel- 
ling in this way. 

Celsus seems to have been fully sensible that when car- 
tilage is once destroyed, it is never regenerated, its place 
being supplied by another substance ;* andMr. Bedingfield, 
whose valuable work I have alluded to before, ingeniously 
conjectures, that the almost uniform fatality of consump- 
tion is owing to the destruction of the cartilaginous matter 
in the lungs. Certainly the mass of corruption presented 
in the chest after death, might make us almost despair of 
ever discovering any measure that shall cure phthisis in the 
last stage. Yet as the suppuration from tubercles is gene- 
rally slow, as it mostly takes place first in one part of the 
lungs, and then in another, and as respiration may be car- 
ried on by a small portion of sound lung, we must not stop 
inquiry by declaring that a confirmed consumption is always 
incurable. Now and then, indeed, we do see patients recov- 
er from the true phthisis, even after they have expectora- 
ted pus, and though such examples are exceedingly rare, 
yet the certainty of their occurrence should make us in- 
crease rather than diminish our efforts : for granting that 
such recoveries have been effected by nature alone, the 

* In aure quoque interdum rumpitur cartilago. Quod si incidit, 
antequam pus oriatur, imponendum glutinans medicamentum est, saepe 
enim suppurationem prohibet, et aurem confirmat. Illud et in hac et 
in naribus ignorari non oportet, non quidem cartilaginem ipsam gluti- 
nari, circa tamen carnem increscere, solidarique eum locum. Cels. 
Tib. Tiii. cap. vh' 



168 PULMONARY CONSUMPTION 

very admission is an encouragement to the endeavours of 
art, since it shows that the disease is not universally fatal, 
that its cure is not physically impossible. But at the same 
time we have surely had experience enough to satisfy us, 
that the inhalation of the gases, which have been recom- 
mended, and other tried expedients, are of no real efficacy 5 
and we should therefore direct our attention to the discov- 
ery of those agents of nature, which yet lie hid, or which, 
if apparent, have not yet been applied. If it be admitted 
that the ulcers in the lungs from tubercles are strictly scro- 
fulous, we have the strongest analogies to conclude, that 
they are not wholly hopeless ; since similar ulcers on the 
outside of the body can frequently be healed by applica- 
tions of a stimulant kind. Now as stimulants can be appli- 
ed to the lungs through inhalation, why should not some be 
tried, the common operation of which is known to be harm- 
less ? The inhalation of the vapour of burning pitch has 
lately been advised, though its power yet remains to be 
proved by more perfect and numerous trials ; but if this 
should utterly fail, others ought to be successively tried, 
with that attention and prudence which the comfort, feel- 
ings, and safety of the sick require. Between the scrofu- 
lous ulcers on the surface of the body and those in the lungs, 
there is obviously a material difference. The surface is 
almost at rest, the lungs are in perpetual motion ; and we 
know that motion generally retards the healing of ulcers. 
Digitalis lessens the motion of the lungs, yet it does not 
seem to favour the healing of ulcers, and this probably 
arises from that general deprivation of energy which follows 
its use. But if any agent could be found to lessen the mo- 
tion of the lungs, without debilitating the system at large, it 
might perhaps be serviceable. We know most satisfactori- 
ly, that pressure favours the cure of ulcers, and hence the 
universal application of bandages to those of the extremi- 
ties. What would be the effect of applying bandages com- 
pletely round the thorax, so that the patient might breathe 
chiefly by the diaphragm and abdominal muscles ? And 
what also would be the effect of laying the head and shoul- 
ders very low, that the pus might not burrow so much in the 
lungs from its specific gravity ? These are questions, which 
can only be solved by experience ; and it appears to me. 



PULMONARY CONSUMPTION. 169 

that they are not wholly undeserving of attention in the last 
stage of phthisis. 

But if, after all our exertions, it should be found, that 
consumption is incurable in the last stage, we may reason- 
ably turn with more sanguine expectations of success to the 
first stage ; for as deranged structure is but the ultimate ef- 
fect of disordered action in chronic diseases, it does not fol- 
low, that, because the first is incurable, the last is also incu- 
rable. On the contrary, many instances might be adduced 
to show, that we actually can arrest disordered actions in 
their commencement, which if uninterrupted generally lead 
to deranged structure, over which we have little or no pow- 
er. From the fairest analogy we have reason to believe, 
that something yet may be done towards the arrestation of 
incipient consumption. We cannot cure gangrene of the 
intestines, but we can stop the inflammation which causes 
gangrene ; we cannot cure caries of the bones, but we can 
frequently remove the morbid action which precedes and 
produces that caries. And why should we not hope that 
some remedy may yet be discovered, capable of preventing 
the formation or arresting the progress of those tubercles, 
which finally derange the structure of the lungs ? Till of 
late years, inquiry seems to have almost stagnated for cen- 
turies on the subject of pulmonary consumption, so far at 
least as practical utility has been concerned. Nay, if we 
turn to the pages of Celsus and of ^Etius, and contrast their 
methods of treatment with those of the present times, we 
shall have no cause perhaps to boast of our superiority. It 
has been said, that fifty-five thousand persons die annually 
of pulmonary consumption in Great Britain ; so that the 
disease may still merit the name of Tabes Anglica, which 
was commonly given to it on the continent a century ago. 
Such an extensive destruction of human life, with all its 
consecutive influence on surviving friends, imperiously calls 
upon the medical faculty for the most strenuous attempts 
either to prevent or to diminish the ravages of this wide- 
spreading malady. It is the grand characteristic of man, 
that he is progressive in those pursuits which supply or 
ameliorate his physical wants, and which at the sajne time 
open and elevate his mind ; and though born the most help- 
le*<% tie becomes the most powerful of all creatures, by re- 
moving or overcoming, through his intellectual powers, the 

22* 



170 PULMONARY CONSUMPTION. 

adverse circumstances which surround him. We have ad- 
vanced far in the medical art, since it was the mere prac- 
tice of staunching blood, and of exhibiting simples, with 
many superstitious ceremonies and spells; and from the 
force of a well-directed perseverance, we cannot fail to ad- 
vance still further, and may perhaps even surmount the 
difficulties of phthisis itself. However great those difficul- 
ties may be, they ought not for a moment to paralyze our 
efforts, but, on the contrary, to be made the occasions for 
renewed and unremitted exertions, until we have done all 
that can be done by human industry. " From torpid de- 
spondency can come no advantage ; it is the frost of the 
soul, which binds up all its powers, and congeals life in per- 
petual sterility. He that has no hopes of success will make 
no. attempts ; and where nothing is attempted, nothing can 
be done."* When we consider how many diseases which 
were once deemed obscure and incurable, have been ren- 
dered quite clear and manageable, we need not despair of 
finally illustrating and controlling pulmonary consumption, 
by minute observation and cautious experience. But in 
the great evils incident to man, an idea that nothing can 
effectually alleviate or remove them, is the most to be de- 
precated ; for it wraps us in the contentedness of apathy, 
when we should have been straining every nerve, and try- 
ing every expedient, in the cause of humanity. Though so 
many ages have passed away, the world is only yet in the 
infancy of knowledge. Much of the information of ancient 
times was necessarily lost, for want of some mean to diffuse 
and preserve it entire ; but as the Press now renders useful 
inventions and discoveries imperishable, the warmest anti- 
cipations of philanthropy and philosophy may be indulged 
with respect to the future. 

By way of putting the subject of consumption into a fair 
train of inquiry, I would propose, that an Institution should 
be founded in London, expressly for the purpose of inves- 
tigating the nature and treatment of this disease; and that 
annual reports of its progress should be laid before profes- 
sional men of every country, with whom a correspondence 
ought to be solicited in regard to its objects. To increase 
astronomical knowledge, Dr. Halley engaged philosophers 

* Dr. Samuel Johnson. See The Adventurer, l$o. 81. 



PULMONARY CONSUMPTION. I7i 

of different countries to watch the transit of Venus over 
the sun's disk ; and surely the consideration of consump- 
tion is of far more importance to the world, a disease which 
yearly occasions the death of so many thousands at the 
most interesting or useful ages. This Institution should be 
upon a large scale, and divided into two departments : the 
one for incipient, and the other for confirmed cases of con- 
sumption. It should be erected in an airy situation, and so 
planned, that each patignt might have an excellent bed room 
and sitting room, opening into each other upon the same 
floor ; and these rooms should have a separate apparatus 
for raising or reducing their temperature to any point re- 
quired, and they ought likewise to be furnished with dou- 
ble windows in cold weather. If this Institution were once 
established, much might be suggested for its internal man- 
agement, so as to make it comprise almost every thing like- 
ly to contribute to the comfort or utility of the patients ; 
and though it would be highly gratifying to me to have the 
medical superintendence of such an Institution, yet if any 
practitioner can accomplish its establishment, I will unre- 
servedly communicate whatever appears in my view most 
fitted to give it beneficial force and effect. 

In the foregoing hints on pulmonary consumption it will 
be perceived, that I have made but few references to re* 
cent authors. Yet this has not arisen from a want of re- 
spect to any of those authors who have written on the sub- 
ject, but simply from a determination, rather to give the 
results of my own observations than the opinions of others, 
that something, however little, might be added to what has 
already been accumulated. My design in publishing these 
imperfect and desultory hints is, in the first place, to stimu- 
late others to prosecute the inquiry of consumption with re- 
newed ardour ; and, in the second place, to suggest what 
have appeared to me as probable improvements in the pa- 
thology, prevention, and treatment. If these ends should 
be effectually answered, my labour shall not have been in 
vain; and if they should not, it will still be satisfactory to 
reflect upon the object of my endeavours. 

Shortly after the publication of the former edition of this 
treatise, Dr. Barlow of Bath favoured me with some opin- 
ions on warm clothing ; and as observation and experience 
have satisfied this distinguished physician that the ordinary 



112 PULMONARY CONSUMPTION. 

mode of employing flannel admits of improvement, it gives 
me great pleasure to insert the substance of his reflections 
here, - 

When flannel is worn next the skin, Dr. Barlow remarks, 
it is almost invariably the practice to keep it on by night as 
well as by day. This is not only unnecessary, but injurious. 
The chief advantage of using a flannel dress next the skin 
results, not from the actual warmth imparted or retained, 
an effect which might be obtained to an equal extent by an 
increase of outward clothing ; but from the uniformity of 
temperature thus ensured to so large a portion of the sur- 
face of the body, and the tendency which this has to keep 
the highly important, but too much neglected functions of 
the skin, in an active and healthy condition. During the 
day the frequent, and oftentimes sudden vicissitudes of our 
climate are such as to render the effects of flannel in pre- 
serving an equality of temperature most valuable. But at 
night, and during sleep, we are subject to no such vicissi- 
tudes ; consequently the same necessity for the use of flan- 
nel does not then exist. But while the use of flannel at 
night thus appears to be unnecessary, there are several con- 
siderations which show it to be injurious. These consider- 
ations regard both the condition of the body and of the 
flannel itself. Whatever the wants of the body for warmth 
during the night may be, they are in general fully supplied 
by the bed-clothes in ordinary use. The body requires no 
extraordinary warmth during sleep ; on the contrary, there 
is at such times even a tendency to an increase of the na- 
tural warmth. When to this natural tendency the heat 
caused by flannel worn next the skin is superadded, the ef- 
fect is to keep the skin in a state of considerable excite- 
ment, and to induce perspiration more or less profuse. 
These effects are not calculated to prepare the body for en- 
during the vicissitudes of the ensuing day, but rather to ren- 
der it more susceptible of injury. Again, continues Dr. 
Barlow, the property which renders woollen cloth so emi- 
nently suited to the purposes in view, is that of its being a 
slow conductor of heat. This property is directly propor- 
tionate to its dryness; and is greatly impaired by its imbib- 
ing humidity of any kind. A flannel dress, however, that 
is worn next the skin throughout the night, becomes so 
charged with perspiration that its power of conducting heat 



PULMONARY CONSUMPTION. 173 

is thereby greatly increased, and its preservative effects 
proportionably diminished. Here then is a twofold injury 
resulting from the prevailing practice of continuing the 
flannel dress during sleep ; namely, a diminution of the 
preservative powers of the flannel, and an increased sus- 
ceptibility of the skin. By laying aside the flannel dress 
on going to bed, and substituting one of coarse calico, the 
body is kept in that temperature during the night which 
iits it for encountering the vicissitudes of the following day, 
while the flannel is preserved from the deteriorating effects 
of the nightly perspiration, and is resumed in the morning 
in a state which contributes both to comfort and protection. 
A difficulty, Dr. Barlow subjoins, is experienced with most 
people who have accustomed themselves to the nightly use 
of flannel, in inducing them, to alter the habit. Fear of 
taking cold creates our great obstacle ; and disinclination 
to the feeling of cold experienced at the moment of chang- 
ing the flannel for the calico nightdress, especially in winter 
seasons, is another. Confidence in the medical adviser, 
however, is sufficient to overcome the first, and a very little 
experience to remove the latter ; for after a very few trials 
the proposed change is found to prove a decided gain, even 
on the score of sensation, and the gratification derived from 
resuming a dry and comfortable flannel in the morning, to- 
gether with the sensible increase of its utility during the 
day, are found to compensate amply the slight unpleasant- 
ness attending the momentary exposure of the preceding 
night. 

Dr. Barlow justly observes, that in many instances, the 
best interests of mankind, whether we consider their physi- 
cal or moral welfare, are influenced by circumstances which 
the world are pleased to deem trivial ; but the above sug- 
gestions on clothing will not be regarded as such by those 
who can appreciate the importance of the subject to which 
they relate, or the talents of the individual from whom they 
proceeded. These suggestions indeed of Dr. Barlow re- 
late to the prevention of disease in general, but to that of 
phthisis in particular, the pathology of which I have proved 
to be closely connected with the skin ; and to show how 
the stateof that organ may influence the cure of this disease, 
it is worth mentioning, that I recently received, from a re- 
spectable correspondent, an account of two cases resem- 



174 PULMONARY CONSUMPTION. 

bling phthisis, which were arrested ; the one by an attack 
of pemphigus, and the other by that of small-pox. 

Some observations having been thrown out in various 
places relative to the balsam of copaiva, and to the sulphur- 
etted hydrogen gas, a few pages shall hereafter be dedi- 
cated to the consideration of their medical properties. 
These two agents, but especially the last, have perhaps 
more efficacy than the profession has yet imagined ; and in 
bringing the sulphuretted hydrogen gas more particularly 
into notice, I shall have an opportunity of offering some re- 
marks on the nature and cure of chronic diseases in general. 



THE MEASLES. 



THE MEASLES. 



FROM an impartial consideration of the facts which 
have come before me, I am inclined to think, that our plan 
of treating the measles is too uniformly active, when the 
eruptive fever is developed 5 and that we should be more 
"fortunate in the main run, if we interfered less with the 
operations of nature in cases of a mild or moderate char- 
acter. Some children do well without the aid of medicine, 
and infants may be easily lost from an excess of applica- 
tions. It is desirable that advice should not be delayed in 
severe, and that it should be cautiously given even in slight 
examples of this disease ; as loss of time may be fatal in 
the former, and too much officiousness dangerous in some 
of the latter. We are in perpetual hazard of doing too 
little or too much in the practice of physic. For it is at 
all times no easy task to make our measures just fitted for 
the removal of the urgent symptoms, without exhausting 
the resources of*the system; and having once adopted 
speculative and practical principles, we are apt to sacrifice 
a great deal to maintain them, so that we sometimes cling 
to fallacies for the sake of appearing consistent. It is too 
much the custom to prescribe for the names, rather than 
for the symptoms of idiopathic fevers. The same species 
of fever, it cannot be too often repeated, may have varie- 
ties so different, as to require different methods of treat- 
ment ; and our means should be changed according to the 
nature of those varieties, that they may, generally speaking, 
be safe in each, and efficacious in all. In briefly discussing 
the measles, therefore, I shall endeavour to show what 
modifications require active, and what gentle expedients ; 
and this distinction may perhaps be of some utility to oth- 
ers, as it was by carefully attending to it, that the results of 
23* 



178 MEASLES. 

my experience have become more satisfactory than at a 
former period. 

The mere outward form and physiognomy of the measles, 
like those of the scarlatina, are liable to make us suppose, 
that there is a great sameness and simplicity in the pathol- 
ogy of this distemper ; but the conditions of the general 
circulation and of particular parts, may be almost as vari- 
ously affected as in typhus or in the scarlet fever, and in- 
deed they form some of its most interesting peculiarities. 
Like every other contagious fever, this has a considerable 
range of character. In one season it will be slight, in an- 
other, urgent, in a third, hold a middle course, and in a 
fourth, assume all its appearances from the most simple to 
the most severe : yet upon the whole, the benign and the 
moderate cases are much more frequent than the violent, 
for an epidemic only occurs now and then, in which the lat- * 
ter decidedly predominate. Whatever may be the efficient, 
the final causes of this diversity of type are, first, that the 
measles are sometimes accompanied by a mild excitement, 
which begins and ends without producing visceral inflam- 
mation ; and secondly, that at other times, in their onset, 
advancement, or decline, they are combined with internal 
congestions or inflammations, which may terminate favour- 
ably or the contrary, according to their degree, or -to the 
time, or to the mode in which they chance to be encounter- 
ed. It is a disease commonly mildest in the summer when 
the weather, is temperate, and most urgent in the winter 
and spring when the weather is cold and variable ; and so 
considerably is it influenced by the habit in which it occurs, 
that sometimes all its varieties may be seen in children of 
the same family, or of the same neighbourhood. At the 
time of its prevalence, therefore, we should attend to the 
states of the atmosphere, and of the constitutions of those 
who are placed within the sphere of its influence : since 
these are the two chief causes which vary the effects of 
the contagious essence, and to them every reigning epidem- 
ic owes most of its leading peculiarities. In unfavourable 
weather we should endeavour to guard even strong children 
against cold, and to keep the bowels open prior to the in- 
fection ; as these precautions, with a light simple diet, may 
do much to prevent serious attacks. The risk of danger 
will be always greatest in those children who actually la- 



MEASLES. 179 

bour under some internal disease, or who are predisposed 
to it, before they sicken of the measles ; but especially if 
that disease, or that predisposition, be seated in the pulmo- 
nary organs. For under such a state of things, when the 
contagion begins to operate, the force of the morbid ac- 
tions is spent on the peccant part ; and that with a rapidity 
which is sometimes perfectly resistless, whatever plan may 
be pursued. On these accounts, subjects of this kind ought, 
if possible, to be removed from the place where the dis- 
temper rages, that they may avoid the chance of being in- 
fected, until a more auspicious time ; and such a step is the 
more requisite when the children are under four years of 
age, because they are liable to suffer most from the circum- 
stances here stated, and because they cannot bear the means 
that may be necessary, so well as at a more advanced age. 
But when a removal into an uncontaminated quarter cannot 
be accomplished, the body should be prepared by mild lax- 
atives and a light cooling diet, for the probable reception of 
the contagion ; and the moment that its effects begin to be 
developed, the greatest care must be paid to ward off any 
threatenings of mischief in a vital region. Where children 
have been afflicted with some previous disease, the tone of 
the constitution is r*ost frequently so much subdued, that 
it is seldom safe to venture on powerful measures when 
they are attacked by the measles. It is generally better by 
an unceasing attention to detect the symptoms early, and to 
endeavour to counteract their tendency by the employment 
of a fetf leeches, a purgative, and a blister, — with the tepid 
bath, if the skin be of an irregular heat : these applications, 
if not carried too far, will be borne well at the onset, and 
may contribute to save the threatened organ from a deci- 
ded attack ; whereas more energetic means might depress 
the general powers, prevent the developement of an equa- 
ble excitement, and induce a dangerous irritation of the 
nervous system.* But in vigorous habits, where there has 
been rather predisposition than positive disease before the 
accession of the measles, we may be bolder, when some of 
the viscera seem too much congested at the commence- 

* Some children, who had previously been sickly, improve much in 
their health, when they get through the measles favourably ; but dis- 
eased subjects more frequently either at once sink under that distem 
per, or become very strumous after surviving its attack. 



180 MEASLES. 

ment ; for then, to the remedies already mentioned, a little 
blood may frequently be taken from the arm with great ad- 
vantage, especially if the patient be above three years old. 
It was formerly noticed, that young children, and even 
adults, occasionally die of a congested brain, without any 
efflorescence on the surface, from the immediate operation 
of the contagion of the scarlet fever ; and I have had some 
strong reasons for suspecting, that the same affection too is 
occasionally produced from the concentrated influence of 
the miasm of the measles. In my treatise on typhus, I at- 
tempted to show, from symptoms and dissections, that more 
or less venous congestion always attends the first obscure 
stage of febrile diseases ; and in the preceding remarks on 
the scarlatina, have given it as my decided opinion, that re- 
action of the heart and arteries, or what may be strictly cal- 
led fever, is the natural cure of that venous congestion. If 
this doctrine be correct, a moderate excitement is favoura- 
ble in those affections which we are wont to consider as 
febrile ; and that this is actually the case, appears to me an 
universal and irrefutable proposition. If we could always 
depend upon the efforts of nature for bringing about re-ac- 
tion, and if that re-action just removed the venous conges- 
tions, without becoming excessive, why then there would 
be little or no occasion for medical interference. But it oc- 
casionally happens, that the venous congestion is so greatf 
as to overpower the efforts of nature, and thai re-action 
would not take place at all, except through an artificial 
agency ; and even when the re-action is developed, whether 
by nature or by art, it is not always exactly proportionate to 
the resistance which it has overcome, but, passing the salu- 
tary limit, itself often becomes a disease. In the treatment 
of fevers, then, there are two great circumstances to be con- 
sidered : the first is, whether nature alone should be left to 
create the re-action - T and the second, whether that re-ac- 
tion be mild or severe, equably diffused throughout the ar- 
terial system, or superabundant in particular parts. It may 
be held as an axiom, that the more marked the symptoms 
are in the precursory stage of fevers, so much the more in- 
tense will be the subsequent re-action ; except indeed , those 
symptoms should be accompanied with so great a congestion, 
as to prevent the developement of the re-action, and there- 
by at once to extinguish life. The converse of the above 



MEASLES. 181 

axiom also equally obtains, as the re-action is mild in pro- 
portion to the mildness of the precursory symptoms. Two 
objects are, therefore, to be regarded in the first stage of 
febrile diseases — the one to attempt the removal of urgent 
congestions without loss of time, and the other to moderate 
the congestions, even when they are not so urgent as to 
threaten the destruction of a vital organ. By accomplish- 
ing the first object, we may frequently save the life of a pa- 
tient, which might be lost under the common routine of 
practice ; and by accomplishing the second, we lessen the 
chances of an inordinate re-action, and thus the chances of 
danger at the same time. 

It must be recollected, however, that the cases are not 
very common in this country, where nature is not adequate 
to the creation of re-action ; and that both the symptoms 
of congestion in the first stage, and those of excitement in 
the second, are often so slight in the measles, as not to de- 
mand any vigorous measures. Yet even in the slighter 
cases of the measles we shall be satisfied, on an attentive 
consideration, that some venous congestion does at first ex- 
ist ; and hence the paleness of the face, the feebleness of 
the pulse, the uneasiness in the head, the torpor of the 
bowels, and the general depression. But as the re-action 
emerges, these symptoms give place to others, and instead 
of a deficiency, there is then an overplus of blood in the 
arteries. The symptoms of congestion in the more striking 
examples are often distinctly evident soon after the child is 
first observed to sicken ; yet they almost always lessen as 
the eruption comes out, until at last all trace of them disap- 
pears in the arterial excitement. Nature here removes one 
action by exciting another, and if the last be sometimes dan- 
gerous, it is always less so than the first ; and hence we 
shall find venous congestions upon the whole, more perilous 
than arterial re-actions. If it were not for the arterial re- 
action which takes place in idiopathic fevers, many patients 
would die of apoplexy, or of an engorgement of some thora- 
cic or abdominal viscus. When the efforts of nature are 
too feeble to create the stage of re-action in the measles, 
the brain and lungs have appeared to me to suffer the main 
pressure of the congestion : but such cases are happily so 
rare, that I have not seen more than perhaps a dozen in the 
course of my experience, in most of which the eruption 



182 MEASLES. 

came out partially at last. Two cases of this sort fell un- 
der my inspection, in which the patients died comatose and 
convulsed, and the lungs were greatly oppressed in both, 
before the disease of the head supervened. An interrup- 
ted respiration may chemically and mechanically affect the 
functions of the brain. It may chemically affect the func- 
tions of the brain, because the blood finally destined to be 
transmitted to that organ does not fully undergo the usual 
changes in the lungs ; and it may mechanically affect the 
functions of the brain, because the attendant impediment 
to the pulmonary circulation, retards the free return of ve- 
nous blood from the head. It is one of the prognostics of 
Hippocrates, that a delirium is bad when it comes on in 
acute complaints of the lungs ; indeed any approach to 
cerebral disorder may be accounted dangerous in pectoral 
diseases ; and we occasionally see children, as well as 
adults, who had become unnaturally loquacious, die sud- 
denly in convulsions, while labouring under pneumonia. 

But in some incipient instances of the measles, coma su- 
pervenes unexpectedly, without any affection of the chest ; 
and though patients commonly expire apoplectic, recovery 
at times takes place under very unfavourable circumstances. 
Ntrt long since I saw a child who lay about four days as if in 
a profound sleep, with its head drawn considerably back- 
ward, and its pupils much dilated ; but, contrary to my ex- 
pectations, it gradually recovered from this state, after the 
application of some leeches to the temples, a blister to the 
scalp, the warm-bath, and the exhibition of active purga- 
tives. In some cases I have seen, before the rash came 
out, the symptoms most strongly indicate a threatened at- 
tack of what is called hydrocephalus internus ; but they have 
almost always readily given way to the abstraction of a little 
blood, purgatives, and the tepid bath ; though I shall here- 
after show that the supervention of water in the brain, at a 
later stage, is no uncommon circumstance in certain modifi- 
cations of the measles. In the example of a child who had 
been recently infected, but who had neither watery eyes, 
sneezing, nor catarrhal symptoms, I pronounced, somewhat 
hastily, the disease to have an actual tendency to water in 
the brain ; because there were intolerance of light and noise, 
contracted pupils, great pain in the head, reddish eyes, and 
extreme restlessness. But on abstracting about three oun- 



MEASLES. 183 

ees of blood from the arm and exhibiting a cathartic, the 
rash of the measles appeared, and the disease ran a mild 
course ; and though the measures employed had probably 
averted the affection of the head, yet the parents of the 
child felt satisfied that I had mistaken the case, because in 
the first instance I had not suspected the measles. This 
fact may serve to put others on their guard as far as their 
own reputation is concerned, and may also teach them not 
to rely always too confidently on the diagnostic signs laid 
down in books ; but whenever an epidemic prevails, the 
practitioner should be especially careful in the delivery of 
his opinion as to the real nature of an incipient fever, since 
it may or may not assume the reigning character. 

Some authors have asserted, that convulsions are favour- 
able in the preliminary stage of the measles ; but I cannot 
consider them strictly so, on account of the symptoms with 
which they are combined. At the attack of the convulsions, 
the signs of great venous congestion will be found distinct, 
the surface pale for want of blood, and the arterial circula- 
tion so languid, that the pulse can scarcely be felt : but as 
contraction of the muscles both accelerates the venous and 
the arterial circulation generally, and promotes a flow of 
blood to the skin particularly, can the pressure of the con- 
vulsed muscles upon the deeper seated veins, in any meas- 
ure, relieve those internal congestions, which immediately 
threaten life ? That muscular action accelerates the arte- 
rial circulation is universally allowed by physiologists, and 
well known even to common observers ; and that it likewise 
both accelerates the venous circulation, and determines to 
the skin, may be shown by familiar examples. The stream 
of blood is increased from the vein punctured at the bend of 
the arm, by moving the nfuscles of that arm ; and hence we 
often make patients turn or grasp something in the hand 
when we wish rapidly to abstract blood. The external 
veins of every person are more or less distended by exer- 
cise, the skin becomes warmer, and the perspiration aug- 
mented, from the greater determination of blood outwards ; 
and these changes are very conspicuously displayed in those 
who follow laborious occupations. Now in reflecting upon 
the various effects of muscular action, it has sometimes struck 
me, whether convulsions themselves might not possibly be 
the extreme struggles of nature to equalize the venous and 



134, MEASLES. 

arterial systems, how ineffectual soever those struggles may 
often prove ; and does not this suggestion borrow some sup- 
port from the circumstance, that the shivering fit, which is 
somewhat related to convulsions, usually contributes to 
bring about the re-action in certain fevers ? Yet were it 
possible to demonstrate the correctness of such an opinion, 
we ought not to leave the convulsions to themselves in the 
commencement of the measles, inasmuch as they are the 
effects of urgent causes, which ought if possible, to be speed- 
ily removed ; and we accordingly find, that measures are 
then often efficacious, which lessen internal congestions, and 
determine to the skin, such as small or moderate abstractions 
of blood, with active purgatives, the warm bath, and blis- 
ters. 

From the drift of the foregoing remarks, it will appear, 
that we ought only to use decisive measures in the first stage 
of the measles, when the symptoms of congestion are imme- 
diately urgent ; and even then we should not push the de- 
pletion too far, as moderate evacuations, aided by the warm 
bath, will answer a much better purpose. It must surely 
have been cases of this character which Dr. Mead had in 
his recollection, when he said, that it is best, if possible, to 
bleed before the eruption ;* for were this principle applied 
indiscriminately to every instance, it might be extremely 
pernicious, by far the greater number of patients requiring 
nothing more than mild purgatives and tepid drinks. Nay, 
there are some in whom the signs of indisposition are so 
slight, that they may be safely left to nature in the com- 
mencement : though even in cases apparently the mildest, 
we should direct parents to watch narrowly the progress of 
the symptoms ; for sometimes before the eruption appears, 
or just as it appears, a sudden change takes place, and a 
tendency to coma, or great oppression of the breathing, 
marks an -incipient and serious attack on the brain or the 
lungs. Yet the consideration of these uncommon occurren- 
ces must not be allowed to incline us too strongly to the 
practice of depletion ; because they rather form exceptions 
from the general character of the early symptoms which, 
from being milder, require less powerful measures at the 

* The Medical Works of Dr. Richard Mead. Vol. ii. p. 152. Ed- 
inburgh : printed by A. Donaldson and J. Reid, for Alexander Do- 
naldson. 1763. 



MEASLES, 185 

attack. And from an extensive trial, I can confidently re- 
commend purgatives as well suited to lessen the congestions 
in the first stage, and thereby to make the re-action more 
moderate than it would otherwise have been in the second* 
What was formerly advanced in respect to the primary 
symptoms of certain examples of the scarlet fever, may tend 
to illustrate the point under review ; but in the measles 
there will be no occasion to administer drastic purgatives in 
nineteen cases out of twenty, and indeed in many they 
would do harm. Simply procuring about two, or at most 
three moderate motions in the twenty-four hours, until the 
eruption appear, will be all that are necessary ; and when 
the eruption has appeared, still we must be more sparing of 
purgatives than in the scarlatina, although to a certain ex- 
tent they are then highly useful, as shall afterwards be 
shown. 

It has been my particular wish, both in this and in a pre- 
ceding publication, to draw the attention of the faculty to 
the primary stage of fevers, because it has hitherto been too 
little regarded 5 to that stage in which the elements of the 
future pyrexia are formed, and which, though occasionally 
very severe, most frequently seems to suspend for a time 
many of the functions between health and disease. The 
venous congestions which exist in this stage of the measles 
not unfrequently leave a predisposition to local affections, 
even when they have given way to the impulses of the gen- 
eral re-action ; for it is a law in the animal economy, that 
when the natural action of any part has been diminished, a 
proportionate accumulation of excitement mostly takes place 
there afterwards. Now as the force of the morbid actions 
in the measles, from the first to the last, is generally most 
concentrated in the respiratory organs, the congestion of 
the first stage necessarily gives them a tendency to increas- 
ed action in the second ; and hence it is, that the chances 
of pulmonary, or indeed of any other internal inflammation, 
are greatly lessened by the generally mild, and sometimes 
moderate evacuations, which have been recommended in 
the first stage of the more distinctly marked cases. It is 
really no substantial objection to this practice, that we can- 
not be positive whether the symptoms for which we pre- 
scribe will always terminate in the measles ; since those 
symptoms are always attended with the risk of constitution- 

24* 



\B6 MEASLES, 

al fever, and often with that of topical determinations, and 
since the same rules apply to them, whether they arise from 
contagion, from cold, or from any other cause, which first 
depresses and then excites the system. The sources of 
what we technically denominate fever are very various ; 
but their grand effects may be reduced to a few similar 
classes, as shall be explained at the close of this work. In 
the primary stage of the most remarkable examples of the 
measles, the vital functions are depressed by a superincum- 
bent load of venous blood : mild or moderate evacuations, 
therefore, but especially by the bowels and the skin, so les- 
sen the venous fulness, as to render it no greater than neces- 
sary to ensure a benign re-action ; and indeed in the slight- 
est cases such evacuations are unnecessary, because the 
congestions are then not more than sufficient for the pur- 
pose of effecting the desired degree of excitement. More- 
over, it is not the chest and head only, that may now and 
then suffer from congestion before the coming out of the 
rash ; for there is sometimes uneasiness in the region of the 
liver, the secretions of which are liable to be retarded or 
vitiated ; and this organ, too, is more frequently affected 
when the subsequent stage of re-action runs high, than most 
authors appear to have imagined. Yet I cannot refrain 
from again guarding practitioners against the extremes of 
doing too much or too little at this early period of the more 
notable cases ; and where the shock from the contagion is 
great, its first depressing effect should be past before blood 
is drawn, as in the case of severe injury from external acci- 
dents. 

Before closing the consideration of this interesting part of 
pathological inquiry as it respects the measles in particular, 
it ought to be remarked, that retching or vomiting, but es- 
pecially the last, seem to be among the most striking means 
by which nature brings about the re-action ; and therefore, 
it may not be irrelevant to inquire whether we should sec- 
ond these efforts when present, and whether we should im- 
itate Jthem when absent. Now when vomiting has been 
present without any alarming symptoms, I have always 
found it best to give nothing auxiliary, except the blandest 
diluents ; but where the lungs have been excessively op- 
pressed, and particularly where vomiting has been absent, 
I have often seen the most striking relief follow an antimo- 



MEASLES. 187 

nial emetic, which may fairly be ranked among the most 
efficacious remedies in pulmonic congestions. In great ve- 
nous congestions of the head, vomiting is generally present, 
and it has probably been too much the fashion, from rea- 
soning a priori, to regard it as an unfavourable circum- 
stance ; in some instances, however, when gently assisted 
by warm water, it has appeared to me productive of much 
benefit, though, from an early and perhaps a weak prejudice, 
I have seldom dared to give emetics in similar cases, unless 
where the stomach was loaded. We have still much to 
learn respecting the use of emetics, and the power of vo- 
miting, in changing the incipient disorders of the circula- 
tion in the first stage of fevers. Having been so much ac- 
customed to the exhibition of purgatives for some years past, 
we have neglected emetics in a most signal manner ; but I 
am fully persuaded, that they will be found both applicable 
and beneficial on the first attack of many acute affections, 
attended with venous congestion. In the first place, an 
emetic gives a universal shock to the system, well calcula- 
ted to produce a complete change of condition ; in the next 
place, it occasions a considerable pressure over the abdom- 
inal viscera, and may thus remove engorgements there, par- 
ticularly about the spleen and liver; and in the last place, 
it powerfully determines the blood to the surface of the bo- 
dy, an effect highly desirable in most internal congestions. 
But what the precise conditions are, under wb^'h emetics 
ought to be exhibited, and what those under which they 
ought to be avoided, I cannot for the present pretend to 
determine ; at the same time I think, that a cautious and 
well conducted inquiry into their influence, in the beginning 
of congestive diseases, is a desideratum in the practice of 
physic. Almost all the medicines which Hippocrates used 
as purgatives, were likewise possessed of an emetic proper- 
ty ; and some of our preparations, such as those of antimo- 
ny, which cause vomiting and purging at the same time, of- 
ten resolve an incipient fever with astonishing rapidity. 
The most important circumstances of the first stage of the 
measles having now been noticed, the subsequent stages 
may be pursued with the more propriety and advantage. 

Between the time of receiving ,the contagion of the mea- 
sles and its actual operation, a few days, or one, two, or 
even three weeks may intervene ; an d fr° m the fi rs * s 'S ns 



m MEASLES. 

of sickening to the appearance of the eruption, a period 
may elapse of twenty-four hours, or of several days. In 
general however, the affection of the skin is later in coming 
out in this distemper after the formation of the fever, than 
either in the scarlatina or in the small-pox. Several wri- 
ters have stated, that the rash appears on the fourth day of 
the fever in the measles ; but as the term fever has not al- 
ways been strictly defined, their meaning is liable to consid- 
erable ambiguity. If under the word fever, these writers 
comprehend the interval of time between the first palpable 
signs of indisposition and the appearance of the eruption, 
the statement is not generally correct, agreeably to my ob- 
servations ; for I have seen the eruption appear at different 
periods in different individuals during this interval, as it is 
then greatly dependent on the states of the systems infect- 
ed, some of which re-act slowly, and others rapidly. But if, 
as it would really seem, these authors mean by the fever 
the developement of the arterial re-action, still I must con- 
tend, that the rash does not uniformly, does not generally, 
appear on the fourth day from the first developement of the 
re-action ; and in support of this opinion, I can most confi- 
dently declare,, that I have seen the rash come out at all 
times between the first and the seventh days from the oc- 
currence of the re-action, though perhaps the most common 
period of its appearance is between the third and the sixth 
day. To settle this point rightly, we must not fix the general 
term of the eruption from a particular constitution of the 
measles, but rather endeavour to deduce it from an extend- 
ed view of different constitutions ; and probably if we were 
to make ourselves acquainted with the circumstances under 
which the rash appears so variously as to time, we should 
be able to account for differences in this particular, and to 
arrange them with a natural precision. It is true that 
there is both regularity and simplicity in the operations of 
nature ; but we frequently frame our ideas of this regulari- 
ty and simplicity, not from a comprehensive, but from a 
limited survey of her works. The current notion about 
the eruption generally coming out on the fourth day of the 
fever in the measles, has probably been taken up and pro- 
pagated on the authority of Sydenham •, but that illustrious 
author appears himself to have drawn his inference from 
one epidemic, which prevailed widely in the year 1670: 



MEASLES. 189 

and he perhaps too precipitately marks as something anom- 
alous another and less extensive epidemic of the year 
1674, in which the eruption came out sometimes sooner, 
and at other times later, than the fourth day of the fever. 
Numerous errors of opinion and of practice, in many im- 
portant concerns of life, may be traced to an implicit reli- 
ance on distinguished authorities ; so natural it is for man, 
who is the creature of obedience, to pay a sort of spontane- 
ous respect to his superiors in rank, in reputation, or in 
genius. 

The watery, heavy, loaded eye, the catarrhal symptoms, 
the less diffused appearances of the rash, and the greater 
feeling of inequality to the touch on certain parts of the 
skin, are generally among the best marks of distinguishing 
the measles from the scarlet fever ; and for the welfare of 
the patient, not to mention the credit of the practitioner, 
these and other diagnostics, which practical authors have 
laid down, should be strictly regarded, as the two diseases 
not unfrequently rage at the same time, particularly in damp 
weather. The catarrhal symptoms often exist several days 
before the rash, and seem in the onset to be among those 
effects of the internal congestions previously noticed ; but 
they are seldom relieved by the eruption at first, nay gene- 
rally become worse for a certain period afterwards, and are 
always connected with less or more disturbed action of the 
arteries, when the fever fully emerges. Though inflamma- 
tion may and does sometimes occur during the eruptive fe- 
ver, it must not be rashly supposed present in every in- 
stance where the cough is frequent ; since, in many cases 
of measles, there is at that time merely an excitement, 
which does not amount to inflammation, of the capillaries 
in the tracheal or the bronchial lining ; and although this 
excitement may maintain a troublesome cough for a time, 
yet in the end it very frequently abates, like an ordinary 
catarrh, as the constitutional fever subsides, and as the ex- 
pectoration of mucus becomes free. In the small pox, we 
see the peculiar pustules not only upon the surface of the 
body, but upon the internal fauces, and they have been 
known to spread even much deeper : now in every case of 
the measles I suspect that an affection, similar to that of the 
skin, exists on the mucous membrane of the air-passages ; 
and perhaps in some instances this affection occupies a 



190 MEASLES. ' 

larger portion of the pulmonic system. In healthy habits, 
however, it often disappears without any manifest inflam- 
mation having been induced ; as we may perceive among 
the children of the lower orders of society, where the mea- 
sles -are so frequently left to run an uninterrupted course. 
But in constitutions of a different cast, in those predisposed 
to pulmonary diseases, by original structure, or by inciden- 
tal causes, the excitement passes on to pneumonia, bron- - 
chitis, or to some similar inflammation in the thorax ; and 
it must, therefore, necessarily be a point of great conse- 
quence to be able to form such a diagnosis as shall enable 
us to determine when we should use the lancet. By long 
associations we are led to intermeddle even with all the 
slighter aberrations from health, without sufficiently reflec- 
ting that they may be only temporary, and that the system 
itself may have the power of returning to its ordinary 
movements ; and indeed we are often prompted to this by 
the entreaties of patients or their friends, by the high esti- 
mation in which the public holds whatever is medicinal, 
and by that selfish principle which too often prompts us to 
do something for the sake of appearance, where nothing is 
actually required. When pain or soreness in the chest, op- 
pressed breathing, general anxiety, and restlessness are ab- 
sent in the eruptive stage of the measles, we shall have no 
occasion to bleed ; and where these are present, venesec- 
tion, either general or local, will almost always be necessa- 
ry. But sometimes it happens, that the breathing is very 
hurried, the cough frequent, and the pulse much quickened, 
about the first coming out of the rash, and yet if we wait 
a day or so, we shall find the respiration gradually improve ; 
and no doubt Dr. Willan alludes to cases of this kind when 
he judiciously observes, that those who from doubt, or from 
some collateral motives, are led to await the event, usually 
find the pulse become moderate and the uneasy respiration 
terminate in twenty -four hours.* In irritable children, and 
especially in infants, the respiration often becomes extreme- 
ly anxious on an attack of simple fever, wholly unconnected 
with pectoral inflammation ; and this is more particularly 
the case when the bowels are disordered. We must be 

* On Cutaneous Diseases. Vol. i. p. 232. By Robert Willan, M. D. 
F. A. S. London : printed for J. Johnson. 1808. 



MEASLES. tfti 

most careful to discriminate such a state of breathing from 
that which commonly attends pulmonic inflammation : nor 
indeed is this difficult, because the former is seldom per- 
manently the same, but varies so much at different times, 
that the patient will seem now much oppressed, and again 
easy ; whereas in the latter, there are no changes of this 
sort in the respiration, for it is so considerably oppressed, 
as never to be entirely easy. Besides, the anxious breath- 
ing, which arises from irritation, is generally increased by 
the erect position, and that which arises from inflammation 
more or less diminished : in the first, the child now and 
then obtains pretty tranquil slumbers, with little motion of 
the chest ; but in the last, the sleeps are always very dis- 
turbed, and the chest may be seen heaving up and down 
with unnatural labour. When any part of the pulmonary 
system is inflamed in children, both the diaphragm and the 
abdominal muscles are generally thrown into an inordinate 
action ; so that if the belly and breast be exposed, one can- 
not fail of being struck with the circumstance ; and forci- 
ble movements of the last named muscles may often be re- 
marked about the navel. In very young children labour- 
ing under pleuritis or any similar affection, we cannot of 
course obtain an account as to the feeling of pain, soreness, 
or uneasiness, and the like, that may exist in the chest ; 
but the permanent oppression of the breathing, the above 
mentioned state of the diaphragm and abdominal muscles, 
the general restlessness, and the peculiar anxiety of the 
countenance, may lead to a tolerably correct opinion. 

When the mucous membrane of the bronchia is attacked 
with inflammation in the measles, the face becomes pale, 
the lips are commonly of a livid or bluish shade, and some 
parts of the skin are cooler and others hotter than natural ; 
while the child, by being attentively noticed, may be heard 
to breathe through phlegm lodged in the air passages, and 
the chest will be seen to heave laboriously. Whenever, 
therefore, these symptoms occur, with an anxious counte- 
nance, and a quickened or oppressed pulse, the practition- 
er should be prompt in his proceedings ; for this is one of 
the most alarming species of inflammation in the measles, 
and is perhaps the most frequent cause of death. In fact 
it assumes the characters of the peripneumonia notha, a dis- 
ease which Sydenham has so well described, but with the 



192 MEASLES, 

nature of which he was unacquainted for want of the light 
of morbid anatomy ; but in all of such examples a careful 
examination after death will show, that the mucous mem- 
brane of the air passages is the part chiefly implicated in 
the inflammation, and the bronchia will be found loaded 
with morbid mucus frequently mixed with pus. 

Where there are no signs indicative of visceral inflam- 
mation in the beginning of the eruptive fever, the principal 
thing to be at first ascertained is, the degree of the general 
excitement of the arterial system : now when this excite- 
ment is by no means great, gentle purgatives and tepid di- 
luents will almost always bring it to a favourable close ; 
but when it runs higher, we must increase the evacuations 
by aperients commensurately, still taking care to determine 
the blood to the surface, by a bland, warm beverage. It 
has occurred to me more than once to have seen the mild 
and the moderate instances of the measles treated various- 
ly — sometimes by bleeding and blisters, sometimes by pur- 
gatives and tepid drinks, and sometimes by nauseating do- 
ses of antimony, according to the different views of the re- 
spective practitioners. The results of these opposite meth- 
ods fully show to me, that the recoveries were the most nu- 
merous and expeditious from the treatment which moder- 
ately moved the bowels, and determined to the skin ; and 
I am now the more convinced of the superiority of that 
treatment in such cases, from an attentive review of many 
which took place in a recent epidemic. From the general 
drift of my opinions, no one, I think, can fairly accuse me 
of being afraid to recommend the lancet ; but my anxiety 
is great to guard against future abuse, from the full convic- 
tion, that it is too indiscriminately, too rashly employed in 
this disease ; and I must therefore repeat, that in the exam- 
ples under consideration, it is very seldom requisite, and 
often hurtful, in very young subjects. Neither upon the 
whole can I agree with those practitioners who,* adopting the 
maxim of Hippocrates, that nature is the best physician, al- 
ways leave the less urgent cases of the measles to them- 
selves, or at most prescribe some placebo for the sake of 
form ; because though such a conduct may oftentimes be 
safer than the contrary extreme, yet there is a middle line 
to be pursued, which will conduct us in the main to the 
most successful results. The measles may be a disease of 



MEASLES. 193 

simple excitement at the onset of the eruptive fever, but 
who can take upon himself to say, that they will observe 
the same character throughout their progress ? In the Epr 
idemics of Hippocrates, we have many cases of febrile dis- 
eases which were allowed to proceed without impediment. 
We accordingly find, that the excitement in some, though 
apparently slight at first, gradually gained ground, and at 
last fatally disordered the functions of some vital organ ; 
and a similar occurrence may be daily observed at this tinje, 
where acute diseases, from some chance or other, have run 
a natural course from their beginning to their end. At the 
same time it must be allowed, that even when left wholly 
to themselves, febrile diseases occasionally have a favour- 
able termination ; as we may perceive in the ancient work 
above noticed, and as we may learn from our own experi- 
ence, but more especially in those fevers termed idiopathic. 
Yet as we can never with certainty infer from the first, that 
an apparently moderate excitement will not produce inflam- 
mation if allowed to advance uninterruptedly, it is safer, as 
a general rule, to pursue such precautions as may at least 
prevent its increase ; and though we may safely leave 
the mildest eases of the measles to nature, there are prob- 
ably few practitioners who are not now disposed to admit, 
that the adoption of the aperient plan has been essentially 
serviceable in many fevers, which were only formidable 
from the local effects resulting from the universal excite- 
ment. 

From the earliest records of physic, it has been com- 
mon to distinguish what are denominated idiopathic from 
Symptomatic fevers ; and though this distinction may have 
been too strongly insisted on, as shall afterwards be shown, 
yet it is certainly of practical utility to attend to it on some 
occasions. For in the fevers which we strictly denominate 
idiopathic, the local affections of an inflammatory nature 
are invariably secondary of the general excitement, and 
not a primary part of the original disease. It is true, in- 
deed, that an ancient doctrine has lately been revived, with 
additional claims to notice, in which every fever is consid- 
ered as the product of some local inflammation ; but this 
doctrine, however beautiful from its simplicity, and how- 
ever respectable from its ingenious support, is so far 
from being generally correct, that local inflammation is far 
25* 



194 MEASLES. 

more frequently the effect than the cause of the constitu- 
tional disturbance termed fever. If we want any proofs of 
the truth of this assertion, they may be found abundantly 
in some of the febrile affections of children, which com- 
mence without any mark of local inflammation, and yet in 
their advancement are accompanied with clear traces of vis- 
ceral inflammation ; and this is so liable to occur in the 
measles, that attacks unalarming in the onset may become 
serious towards the close, from the supervention of an in- 
flammatory disease of some vital organ. It has been here 
and elsewhere noticed, that venous congestion, and not the 
arterial disorder called inflammation, is the essential part 
of the first stage of most fevers ; and the venous conges- 
tion seems not unfrequently to leave a tendency somewhere 
to inflammation, which is often called into existence by the 
mere continued force of the general excitement. It is up- 
on this principle, therefore, that I deem it safer to procure 
mild or moderate discharges from the bowels and from the 
skin in the less urgent cases of the measles, than to allow 
them to take a natural course ; and the propriety of this 
treatment will be the more apparent, when we reflect, that 
it may not only prevent sudden inflammation, but those of 
a slow and insidious kind, which are so liable to arise out 
of an uninterrupted excitement. 

In the apparently moderate instances of this disease, 
small doses of castor oil, of the sulphate of magnesia with 
the infusion of senna, or of rhubarb and magnesia, may be 
so exhibited as to procure about two evacuations in twenty- 
four hours, during the progress of the fever ; and when the 
excitement is somewhat greater, four or five grains of calo- 
mel may be daily added to the above medicines, and this 
preparation is then more necessary, as the abdominal se- 
cretions will usually be found vitiated. These simple 
methods, with an occasional small opiate at bed time, and 
a strict antiphlogistic regimen, will answer every purpose in 
a large majority of such examples ; and where the chest 
may be seemingly threatened by a topical determination of 
blood, an antimonial emetic, with the tepid bath, will fre- 
quently preclude the necessity of having recourse to more 
vigorous means. Indeed a little of the pulvis antimonialis 
may often be combined advantageously with the laxatives, 
as it tends to keep up an action on the skin, aided by the 



MEASLES. 195 

warm diluents. Some authors have stated, that even mo- 
derate purging is apt to cause a retrocession of the rash in 
the measles, but I have not met with an instance of this 
kind in my own practice ; and so far from having found 
laxatives at all hazardous, when properly administered, 
they have almost invariably appeared useful throughout the 
eruptive fever. The dread of aperient medicines is pro- 
bably to be attributed to the influence of an old doctrine 
which was once in the highest repute, and which, descend- 
ing from the faculty to the public, is still firmly rooted 
among the common people, especially in the minds of old 
nurses. The abettors of this doctrine supposed that, by 
emptying the vessels, the peccant humours, which ought to 
be discharged, were prevented from coming out by the skin, 
their proper emunctory ; and upon such an airy basis were 
founded many imaginary fears, which long turned profes- 
sional men from an inquiry into facts, by which they might 
have been at once dissipated. When we consider, that 
some of the ancients, and particularly Alexander, who 
flourished in the time of Justinian, successfully exhibited 
purgatives in acute fevers, it is somewhat remarkable, that 
they should afterwards have fallen into general disrepute. 
We owe it chiefly to Dr. Hamilton, that their reputation 
has been restored in modern times ; and if that excellent 
physician had given them a fair trial in the measles, he 
would have found their efficacy unquestionable ; although 
they cannot, or rather ought not, to be carried so far in this 
as in the scarlet fever, on account of the peculiarity of the 
rubeolous eruption and of the pectoral symptoms. When 
a copious diarrhoea occurs spontaneously at the beginning 
of the stage of re-action, we sometimes see it check the 
progress of the rash, while the breathing at the same time 
grows more oppressed ; and such occurrences should cau- 
tion us against instituting any thing like hypercatharsis, 
which might have similar effects at this period. There is 
a very striking sympathy between the lungs and the skin, 
and between the skin and the bowels, in the measles ; inso- 
much that excessive purging diminishes the flow of blood 
too much towards the surface, and this effect re-acts, in its 
turn, unfavourably on the respiratory organs. But on the 
contrary, a gentle action on the bowels is always beneficial : 
it restrains the general excitement, and wards off topical 



196 MEASLES. 

determinations, without the risk of oppressing the chest. 
In proportion, therefore, that excessive purging is to be 
censured, so is the moderate use of aperients to be com- 
mended in the class of cases which has just been consider- 
ed ; but during their exhibition and operation, the skin 
should not only be guarded from cold, but tepid diluents 
should be given to maintain the circulation of the surface. 
It is one of the most correct and valuable observations of 
Hippocrates, that burning fevers seldom get a considerable 
head where the belly is loose ; and it is the peculiar advan- 
tage of laxatives, that they are applicable to all of such af- 
fections, whereas venesection is only proper for the more 
aggravated forms. 

The excitement, then, may be so much controlled in nu- 
merous cases of the measles, by laxatives, antimonials, and 
the antiphlogistic regimen, that we may dispense with vene- 
section ; but the certainty of this fact should not make us 
invariably rely on these measures, as the disease is not of 
one uniform character. Inflammation may suddenly super- 
vene in the beginning of the eruptive stage, or it may gra- 
dually arise during its progress. When it supervenes sud- 
denly, it is in general strongly marked, but when it arises 
gradually, it may be insidious for some time : and these two 
forms of inflammation, the one acute and the other sub- 
acute, should be equally the objects of consideration, that 
we may attack the first promptly, and not be deceived by 
the second. The signs of the acute inflammation of the 
chest have been already enumerated ; and the sub-acute 
inflammation of that quarter may be best detected by daily 
attending to the respiration, which becomes more or less 
oppressed as it supervene. The mucous membrane of the 
trachea or bronchia, the pleura or the parenchyma of the 
lungs, are the parts most frequently attacked by inflamma- 
tion : but sometimes it begins about the tonsils or in the 
pharynx, and, suddenly or gradually spreading to the wind- 
pipe, constitutes the laryngitis of some recent writers, or 
the more common affection called the croup, or, being 
deeper seated, brouchitis ; though the fact is, that the mu- 
cous membrane of the larynx, trachea, and bronchia, is 
most frequently more or less affected throughout its extent. 
When the mucous membrane of the windpipe is inflamed, 
the secretions of the villous coat of the intestines common- 



MEASLES. 197 

ly become morbid : indeed, there is a sympathy between 
tissues of the same structure, which, though Bichat has al- 
luded to it, is still very open to investigation. Next to the 
lungs, the liver is most liable to inflammation, which in that 
organ is generally so obscure as to be masked under the 
pectoral symptoms : but it, or some similar disease in the 
belly, may always be suspected where sickness or vomiting 
continues after the coming out of the rash ; and where a 
diarrhoea occurs at this early period, with occasional griping 
and hurried respiration, that also is often connected with 
some abdominal inflammation. Flatulence of the stomach, 
unnatural stools, and pain or soreness on pressure, are 
among the surest signs of such affections ; and when the 
patient cannot turn upon the left side without uneasiness 
under the ribs of the right, the liver is decidedly disordered. 
Before the appearance of the eruption, clear marks of ce- 
rebral fulness often exist, but these almost always recede 
after its free appearance ; so that inflammation of the brain 
is rare during the height of the measles, except the rash 
suddenly recedes. Indeed, the sudden and premature fa- 
ding of the rash is most frequently the commencement of 
some internal inflammation or congestion of a serious kind. 
When there are sufficient grounds for inferring the exis- 
tence of inflammation in the measles, general venesection 
should mostly be employed as early as possible ; and in 
those obscurercases, where the symptoms rather indicate 
than reveal inflammation, the best general rule will be to 
try local bleeding, as this cautious procedure may do good 
in the beginning, and cannot do any harm. It should, how- 
ever, be our constant endeavour to proportion the measure 
of the depletion not only to the degree and stage of the in- 
flammation, but to the powers and peculiarities of the pa- 
tient. We shall hardly ever have occasion to regret when 
we bleed at the onset of inflammatory diseases ; but when 
we venture upon general venesection late, we most fre- 
quently risk whatever chances of recovery may remain. 
In the commencement of inflammatory diseases we operate 
on vantage ground, and may proceed boldly ; but our po- 
sition is reversed in the last stage, and great caution is then 
necessary at every step. The strength is only suppressed 
in the first stage, it is exhausted in the last. General 
bleeding arrests the topical disorder in the first stage, with*' 



I9S MEASLES. 

out weakening the system further than is necessary for the 
removal of that disorder ; and the general debility resulting 
from the loss of blood is much less than that which the un- 
impeded disease would have caused, not to mention the 
tendency of inflammation to derange the structure, or to 
destroy the functions of the affected viscus. But towards 
the close of inflammatory diseases, the energy of the heart 
and arteries, with that of the whole body, is wasted, from the 
local and universal excitement ; and general venesection at 
that time exerts little or no influence on the topical disor- 
der, whilst it has an inverse one on the system at large, 
which it may immediately and mortally overpower. Yet 
between the first and the last stage, and particularly in sub- 
acute inflammations, there is a middle one in which moder- 
ate venesection is often very useful : moreover, it is a prin- 
ciple of physic, that whenever any just reason exists for 
hesitating about the employment of general blood-letting, 
local should always be preferred ; and in young children 
the latter will sometimes do much good, when properly as- 
sisted by purgatives and blisters. Great difference of opin- 
ion prevails among writers relative to general blood-letting 
in the acute complaints of young children, some advising, 
and others censuring the measure. In this, as in every 
medicinal dispute, we must endeavour to separate our pre- 
judices and partialities from those fixed principles which an 
unbiassed experience has established. Sydenham asserts, 
that general bleeding may be as safely performed in young 
children as in grown persons ; and he proves its efficacy, 
in those, by having employed it successfully in peripneumo- 
nic fever, in convulsions from dentition, and in severe ca- 
ses of hooping-cough. But, although on the whole, the de- 
pletory practice has maintained its ground in the measles 
since the time of that illustrious physician, many practition- 
ers have abandoned general for local bleeding in very young 
children ; and so far as I have been able to collect from 
modern publications, the change is not confined to this dis- 
ease alone, but has been extended to most of the acute af- 
fections of such subjects. One would naturally suppose, 
that this change, sanctioned as it seems to be by numerous 
authorities, was a substantial improvement ; nevertheless, 
perhaps, a candid inquiry might prove, that if the older au- 
thors neglected local bleeding too much, the modern have 



MEASLES. I9d 

Committed a similar mistake with regard to general bleeding 
in young children ; for I believe it will be found, that in 
some instances general is preferable to local bleeding, and 
vice versa, whilst again in others a combination of both may 
be best. In all the most acute attacks of the visceral in- 
flammation of young children, general is better than local 
bleeding in the first instance, because it makes a greater 
impression on the universal excitement, and on the topical 
affection ; but m the less urgent attacks of disease, where 
there appears to be rather increased determination to, than 
positive inflammation in, an internal part, local abstraction 
of blood is perhaps superior. Besides, as the latter, too, 
may be preferable in young children of a delicate frame, so 
in those that are robust, the former has the most decided 
advantage ; and both may sometimes be employed with 
excellent effect, where the violence of the symptoms indi- 
cates the vital necessity of immediate relief. 

An expert surgeon will hardly ever be baffled in bleeding 
young children ; for if a vein cannot be found at the back 
of the hand, or at the bend of the arm, a branch of the tem- 
poral artery, or the external jugular vein, may easily be 
opened, but especially the latter ; and indeed the external 
jugular is decidedly the best place to bleed children, when 
we are desirous to free a vital organ from fulness by the 
rapid abstraction of blood. The integuments immediately 
lying over the external jugular vein may be drawn up be- 
tween the fingers, and then cut transversely, the better to 
expose this vessel ; after which it ought to be pierced, very 
slightly oblique, and the blood will commonly flow in a 
stream, if the vein be pressed by the thumb a little below 
the opening. Or when the right jugular vein is opened, a 
bandage may be passed over it and fastened under the left 
arm pit, its direction of course being reversed when the left 
is opened ; but if the operator can secure the vein from 
rolling, he may at once penetrate it through the integu- 
ments, which is often the best mode. When a sufficient 
quantity of blood has been taken away, the vein should be 
carefully secured, and frequently examined afterwards, if 
the child be restless ; for, owing to an omission of such pre- 
cautions, I have known it bleed again very profusely and 
dangerously, but especially when children had been neglec- 



200 MEASLES. 

ted in the night.* But after having made so many prelim» 
inary observations respecting venesection, it may be natu* 
rally inquired, how much blood ought to be taken away in 
the inflammatory diseases of young children ? It would be im- 
possible to impose any rule correctly applicable to every case. 
At the completion of the first year, three ounces may be ac- 
counted a moderate bleeding, four ounces at that of the sec- 
ond, and five at that of the third ; but after a child has passed 
his fourth year, and has been tolerably healthy before, he 
will bear general bleeding much better than prior to that 
period. Some surgeons of my acquaintance draw blood 
much more freely than above stated in the inflammatory af- 
fections of young children ; and on some occasions, I have 
myself gone considerably further with advantage, but then 
the symptoms have been extremely violent. It has always 
appeared to me one of the nicest points in the practice of 
physic, to bleed young children judiciously when attacked 
with visceral inflammation ; for if we stop too short, the 
inflammation goes on and destroys them : and if we advance 
too far, the excess of depletion is destructive, though it 
should subdue the inflammation. The young differs from 
the mature constitution in having a more intimate and ex- 
quisite relation, by sympathy, between the vascular and the 
pervous systems ; so that more powerful effects are produ- 
ced from depletion in the one system, and from irritation 
in the other, than are observable in adults. Nervous irri- 
tation hurries the circulation more in children than in men ; 
and loss of blood produces more irritation in the former 
than in the latter. Now we hardly ever see children la- 
bouring under" any inflammatory complaint without the 
nervous system being highly irritated at the same time ; 

* A professional friend bled a child, that laboured under the croup, 
from the external jugular vein ^ and the difficulty of breathing conti- 
nued so great afterwards, as to force the blood out repeatedly from the 
orifice, though compresses had been carefully applied. At last he pas- 
sed a very fine needle through the incision, which he closed with the 
twisted suture, after the manner that the veins of some of the lower 
animals are secured. This answered the purpose completely. The 
child, however, had previously lost an excessive quantity of blood, but 
it ultimately recovered. In opening the external jugular vein in 
children, we shall perpetually expose them to the risk of hemorrhage, 
if the vessel be cut across ; but this will seldom be the case, if it be di- 
vided in a very slightly oblique direction, as has been already recom- 
mended. 



MEASLES. 201 

and we must constantly bear in mind, that we have a double 
object in view — the first, to arrest the inflammation, and the 
second, to allay the irritation. It is on account of this mutu- 
al relaiion, that moderate bleedings are generally so effica- 
cious, and large ones frequently so hurtful in the inflamma- 
tory fevers of children ; for the first check the inflamma- 
tion without increasing the irritation, whereas the last in- 
crease the irritation to so high a degree, that it often ex- 
hausts the vital energy. Let any one attend to the pulse of 
a young child after moderate bleeding in an inflammatory 
complaint, and he will feel that it is generally calmer than 
before ; but after profuse venesection, he will find it trem- 
ulously rapid, the whole system participating in the nervous 
agitation. After bleeding, therefore, it is of great conse- 
quence to keep children as tranquil as possible, and if much 
irritation should supervene, it ought to be allayed by the 
tepid bath, or by an opiate ; indeed, where very great irri- 
tation succeeds venesection, I am confident that many 
children may be saved by the exhibition of a few drops of 
laudanum, with a little light food afterwards. These gene- 
ral hints are specially applicable to the measles when com- 
bined with inflammation, and when occurring in children 
under four years of age ; for if we be moderate in the use 
of depletion, we shall most frequently save them, whereas, 
if we bleed too profusely, they will generally sink under 
the shock which the nervous system sustains. 

When inflammation attacks the pleura during the erup- 
tive fever, it generally spreads to the lungs, so that the lat- 
ter after death will frequently be found harder than natural, 
from an effusion of lymph into their substance ; and this 
appearance of the lungs of children who die in the measles 
is perhaps more common than after the fatal termination of 
simple pneumonia from cold, or a like ordinary cause. In 
attacks of this nature, it will commonly be best to combine 
general and local bleeding at the same time ; for the first 
will directly abate the force of the universal excitement, 
which partly maintains the topical disease, and the last will 
have a direct influence upon the inflamed portion of the 
pleura, by reason of the free anastomoses between it and 
the integuments of the chest. When these steps have been 
taken, but not till then, a blister may be beneficially applied 
over the site of the pain. It has sometimes struck me very 

26* 



202 MEASLES. 

forcibly, that the precipitate application of blisters to the 
chest, before general or local blood-letting, is a prejudicial 
practice ; at least, I have occasionally seen hydrothorax rap- 
idly follow it, from the increase of the general and topical 
excitement which blisters, thus applied, had apparently pro- 
duced. This point, therefore, is perhaps deserving of fur- 
ther investigation in the acute pulmonary inflammations, to 
which it chiefly relates. In conjunction with the above 
measures, purgatives should be moderately administered ; 
but more especially if the liver or some other abdominal 
viscus is simultaneously inflamed. Affections of the chest 
may not only exist simultaneously with those of the liver in 
this distemper, but they may also follow as an effect of in- 
flammation in the latter organ, and then the mucous mem- 
brane of the trachea is more liable to be attacked. When 
some of the thoracic viscera are solely inflamed, laxatives, 
rather than purgatives, should be exhibited ; as the last of- 
ten tend to diminish expectoration, an effect rarely witnes- 
sed from the first. When the mucous membrane of the tra- 
chea is itself inflamed, or when the bronchial passages are 
loaded with phlegm from pulmonic, pleuritic, or hepatic in- 
flammation, an antimonial emetic frequently gives great re- 
lief; and it may sometimes be advantageously repeated 
when the secreted mucus so accumulates as to impede the 
respiration, and thus to oppress the whole system. In such 
examples, the continued use of nauseating doses of antimony 
are sometimes highly beneficial after the operation of an 
emetic. If the breathing be laborious from any pulmonary 
inflammation or congestion, nature often seems to attempt 
their removal by a copious effusion of serous fluid from the 
capillaries of the air passages : where this effusion is very 
freely expectorated, patients generally do well, but if it be 
retained as it is secreted, it not unfrequently tends to pro- 
duce suffocation, particularly in children ; and it is in cases 
in which the expectoration is defective, that the shock of 
an emetic, by dislodging the phlegm, and inducing a change 
in the action of the heart may save the life of some patients. 
The warm bath, strongly impregnated with salt, is often 
beneficial in pulmonary inflammations, but especially in 
those of children. After its use I have often seen the wheez- 
ing and dyspnoea much abated ; and indeed it may be rank- 
ed among the best secondary means for such affections. It 



MEASLES. 205 

may be recurred to at any time when the general habit is 
highly irritable, or the respiration greatly oppressed ; and 
under these circumstances it sometimes has all the soothing 
effects of an opiate, besides relieving the chest by means of 
a copious perspiration. But still I must again be allowed 
to caution the practitioner against an excess, or a deficien- 
cy, of depletion. There is a golden medium between these 
two extremes, which at once arrests inflammation, without 
inducing general exhaustion, or a consequent arterial re- 
action combined with nervous irritation ; and this golden 
medium must be the more particularly observed with chil- 
dren labouring under inflammations, as they may be equal- 
ly lost by too small, as by too large evacuations. Nor 
should we continue to teaze children, as is often done with 
adults, by a long succession of various expedients, as this 
would exhaust the strength, even if it subdued the disease. 
All our efficacious agents should be brought to operate 
within a short time, and then we should endeavour to allay 
the united irritation of the disease and of the remedies by 
mild treatment ; for if we fail to stop the inflammation in 
the first instance, by persevering in active and irritating 
measures, we shall only contribute to precipitate the patient 
to the grave. 

It must not, however, be supposed from what has just 
been written, that inflammation is an invariable occurrence 
during the eruptive fever : since, for my own part, I have 
not very often seen it take place where proper attention 
has been paid to lessen the congestions in the first stage, and 
to moderate the excitement and allay the irritation in the 
second ; though at the same time it must perhaps be admit- 
ted that inflammation is not uncommon at this period, when 
the early symptoms have been mal-treated or neglected. 
Many authors state, however, that inflammation is not very 
common at this period of the measles, though from the 
writings of Morton, Mead, and others, it is clear that epi- 
demics have occurred, which were throughout most deci- 
dedly inflammatory ; and this appears to have been partic- 
ularly the case in the time of the last mentioned writer, for 
he says, that the measles always brought with them a peri- 
pneumony which required bleeding.* But one of the most 

* See vol. ii. p. 154, of the edition of Mead's Works, before quoted. 



204 MEASLES. 

remarkable accounts on record of this distemper being com- 
bined with inflammation during the eruptive fever, is that of 
Sir William Watson, in the fourth volume of the Medical 
Observations and Inquiries ; though it is certainly to be re- 
gretted that he designated the epidemic which he saw as a 
putrid species of the measles. This defect, however, was 
interwoven with the pathology of the times, and is not, 
therefore, strictly his own. So far have we advanced since 
then, that no correct writer would now call any disease pu- 
trid, the primary symptoms of which were highly inflamma- 
tory. But if Sir William erred as to the imposition of the 
name, it must be allowed, that he has most ably illustrated 
the nature of the epidemic ; and his division of the symp- 
toms into a first and second stage is a master-piece of pa- 
thological arrangement. In the first stage, the inflamma- 
tion ran high, and active depletion was useful, as nine pa- 
tients out of ten were saved in the worst modifications : 
whereas in the second stage, this practice was entirely in- 
admissible, on account of the general collapse, and the local 
derangements which the first stage had effected, when it 
held an uncontrolled progress. Dr. Willan has attempted 
to show, that Sir William mistook the scarlet fever for the 
measles ; but the ground of his objections is perfectly un- 
tenable, and it is to be regretted that this able physician 
should have advanced so vague an opinion on the subject. 
Among numerous proofs that might be adduced in support 
of the accuracy of Sir William Watson's judgment, it is 
enough to mention, that the peculiar*, sloughy sore in the 
throat, which attends all the aggravated forms of the ardent 
scarlatina, was absent in the disease that he has described :* 
indeed, the two most prominent peculiarities of the epidem- 
ic, the early appearance of the eruptive fever, and the pu- 
trid symptoms in the last stage, I have myself sometimes 
witnessed in the measles. The history of such violent mod- 
ifications of this complaint is well calculated to caution us 
respecting that variety of form which all epidemics are liable 
to assume ; since it is one of the most common and lament- 
able errors of systematic writers, to lay down limited rules 

* See Medical Observations and Inquiries, by a Society of Physi- 
cians in London. Vol. iv. p. 1 32. The Second Edition. London i 
printed for T. Cadell, in the Strand. 1772. 



MEASLES, 20!> 

of treatment under a certain name, as if the character of 
the disease thereby designated were invariably the same. 

One or two observations have already been made con- 
cerning the irregularities in the character of the rash, but it 
may not be amiss, perhaps, to be somewhat more particular 
on this point. In most of our methodical works it has been 
stated, that the sudden and premature retrocession of the 
rash is followed by dangerous symptoms : but although this 
is the case in many instances, yet in some no bad symptoms 
whatever supervene, and therefore the assertion has been 
expressed in too general terms. Whilst in attendance upon 
patients labouring under the measles, I have commonly left 
directions to immerse them in a tepid bath of salt water, 
immediately on the untimely fading of the eruption : and 
this expedient, with frictions of the skin afterwards by 
warm flannels, has generally answered every purpose in the 
slighter, while it has contributed to relieve even the more 
urgent examples. Rhazes seems to have used the vapour 
bath and frictions in occurrences of this sort ; and certainly 
if we can only restore the eruption by a free flow of blood 
to the surface, the relief will most frequently be immediate 
and permanent. Cold applied to the skin, and an attack 
of some visceral congestion or inflammation, are the most 
usual causes of repelling the rash before its common time : 
but in two or three instances I have seen it disappear per- 
manently after copious venesection, — a proof that the 
eruption consists in some peculiar state of the extreme ves- 
sels, without any effusion under the skin.* If the partial 
or general fading of the rash be connected with some visce- 
ral congestion or inflammation, the plan of treatment must 
be pursued which has been before pointed out for similar 
affections ; and it must be recollected, that in urgent in- 
stances the execution of this plan must be prompt and de- 
cisive, the local congestion or inflammation being then par- 
amount to every other consideration. On such occasions, 
the lungs, the brain, the liver, or the bowels, in general bear 
the pressure of the internal disorder. The affection of the 
lungs may be known by the sudden and marked disturbance 

* Whenever faintness is induced by bleeding in the measles, the 
rash almost always disappears either entirely or partially, or at least it 
becomes much less vivid ; but it generally returns to its ordinary state 
as soon as the re-action again takes place. 



206 MEASLEfe. 

of their functions, and that of the brain by coma and deliri- 
um, the first a sign of congestion, and the last of inflamma- 
tion ; whilst the affection of the liver or bowels will be 
denoted by some abdominal uneasiness, which is for the 
most part combined with an apparent looseness, and there- 
fore we must be mindful not to confound an inflammatory 
attack of this kind with simple diarrhoea. And at the same 
time we ought to be equally attentive not to mistake for 
genuine coma, the mere heaviness or sleepiness which so 
often occurs in the beginning of the measles, from which 
the child can always be roused at pleasure, and which dis- 
appears as the rash comes out ; for although this heaviness 
or sleepiness be an indication of a degree of cerebral con- 
gestion, yet it is generally cured by the eruptive fever, or 
may be removed by laxatives ; whereas the genuine coma 
is always alarming, it requires more active measures, and is 
attended with twitchings, startings of the tendons, convul- 
sions, or with an obvious bending back of the head towards 
the spine. After an attack of the measles, when all cause 
of present apprehension is past, and when the eruption has 
faded at its usual term, children often fall into a long and 
quiet sleep, in a natural position, and with a warm, moist 
skin, slow pulse, and gentle respiration. But this is only 
the tranquillizing repose of nature, which succeeds disease, 
like serenity after the storm ; and it is neither to be con- 
founded with coma nor interrupted, being almost always a 
certain presage of convalescence. There is, however, one 
congestive disease connected with irregularity in the erup- 
tion, which deserves something more than general remarks, 
on account of its uncommon and serious character. Occa- 
sionally children are at once attacked by an extreme diffi- 
culty of breathing, mostly without, or with very little expec- 
toration, on the first appearance of the rash, which either 
soon entirely recedes, or remains out partially, and is of a 
darker colour than natural. The face in such instances is 
very pale, and the skin usually of an irregular temperature, 
cold or cool in some places, and of a preternatural heat in 
others, while the pulse is low, quick, and struggling. The 
patient, if not promptly relieved by the warm bath, moder- 
ate bleeding, an antimonial emetic, a purgative, and a blis- 
ter, sinks rapidly under an apparent load of phlegm in the 
bronchia, with wheezing and the most laborious respiration ; 



MEASLES. 207 

and on examining the body after death, the lungs will almost 
always be found congested with dark blood, the capillaries 
of the mucous membrane of the bronchia highly injected, 
and the air passages obstructed by an effusion of unnatural 
mucus. The pathology of this form of the measles seems 
to resemble that of certain cases of spasmodic asthma, in 
which there is venous congestion of the lungs, with an ob- 
struction in the circulation of the capillaries of the bronchi- 
al lining, and in which a mucous effusion takes place into 
the bronchia, apparently as an effort of nature to relieve the 
respiratory organs from the great surcharge of blood. But 
as children cannot bear an oppression of the lungs so well as 
adults, so they far more frequently sink under its influence 
than the latter. In union with the means above stated, I 
have seen in some instances of the disorder under discussion 
the most decided benefit, after depletion, from a large dose 
of calomel, a little camphor and pulvis antimonialis with a 
few drops of laudanum, this combination acting powerfully 
on the skin ; though, upon the whole, bleeding, blisters, an- 
timonials, and the warm bath are the most to be relied on 
in such concentrated attacks of pulmonary affection. 

In the most notable forms of the irregular measles, where 
the excitement is either suddenly suppressed or very une- 
qually developed, the disease does not run a determinate 
course, generally ending fatally or favourably before the 
usual time ; and the same observation obtains in those ir- 
regular forms of the scarlet fever which have been already 
discussed, and is perhaps alike applicable to the small pox, 
the plague, and genuine typhus. But where the excite- 
ment is universally developed, the measles, like some other 
exanthemata, have a sort of determinate duration, whatev- 
er may be done. The cause of this probably is to be sought 
in the continued irritation of the morbific principle gene- 
rated during the excitement of the measles, by which the 
complaint acquires the property of infecting others indefi- 
nitely, who have not previously been under its influence. 
This determinate duration of the measles, and similar dis- 
tempers, has led some medical writers to doubt the efficacy 
of medicine ; since they seem to conceive it cannot be of 
any material benefit, seeing that it has not the power of 
controlling the continuance of the disease. Nothing, how- 
ever, can be more fallacious than such an argument ; for if 



m MEASLES. 

it be granted to the full, that medicine cannot shorten the 
measles, still it does not follow that it is of no use. When 
an universal excitement of the arterial system takes place 
in a sound subject, it is at first unaccompanied with local 
inflammation, and sometimes ends without producing any : 
but if it be not moderated, even in such favourable habits, 
it not unfrequently involves some important organ in in- 
flammation during its advancement ; and when such an ex- 
citement occurs in a constitution where some viscus had 
previously been in a weakened or faulty condition, that 
viscus is sure to become inflamed, from the mere impulse 
of the hurried circulation. In fact, the more cautiously we 
investigate the primary and successive phenomena of fe- 
brile diseases, the more we shall be convinced that local 
inflammation is always the result of the general excitement, 
in those fevers which are ushered in by a cold stage ; and 
as the seat of that inflammation is generally determined by 
some latent defect which had before existed in the organ 
attacked, so the weakest habits are the most, and the sound- 
est the least, subject to visceral inflammations from any 
general shock that takes place. In what are called symp- 
tomatic fevers the visceral inflammation is soon declared, 
and therefore it has commonly been deemed the link by 
which all the morbid chain of symptoms is suspended ; but 
in what are called idiopathic fevers, the inflammation gen- 
erally arises at a later period, and more insidiously, from 
the continued excitement gradually obstructing some part 
of the capillary circulation. It is on this account that what 
we term idiopathic fevers require such attentive watching 
from their commencement, and in their course ; because, 
if we daily moderate the excitement, we shall generally 
succeed in ensuring a favourable issue, by preventing topi- 
cal inflammations. 

The cold affusion has been successfully tried in the erup- 
tive stage of some cases of the measles ; and where the 
heat of the surface was intense, I have myself in a few in- 
stances, used the tepid affusion with apparent advantage. 
Still, however, the skin is frequently so susceptible of ex- 
ternal impressions, and the pulmonary organs thereby so 
liable to be affected, that I suspect the cold affusion will 
never be generally applicable, as in the ardent and open 
forms of the scarlet fever. It is true, that among the lower 



MEASLES. 209 

orders of society, children are not unfrequently allowed to 
go about without restraint in the air, while labouring under 
the milder attacks of the measles ; and as several thus ex- 
posed pass through the disease well, this alone affords proof 
that the application of cold to the skin is at least not preju- 
dicial in such examples But then, again, in the greater num- 
ber of those cases to which I have been called, where the 
rash had suddenly receded with alarming symptoms, I found 
that the children had been negligently exposed to cold air • 
and surely examples of this nature authorize us to infer, 
that however harmless such an exposure may sometimes 
be, it is at other times highly dangerous. We therefore 
seem to want facts to enable us to determine under 
what precise circumstances the application of cold to 
the skin is useful at one time, and prejudicial at an- 
other ; and it would be the extremity of rashness in the 
present state of our knowledge to conclude that the cold 
affusions are suitable to all the forms of this disease, be- 
cause they have been advantageously applied in a particu- 
lar f >rm. Yet if any remedial agent should answer in one 
variety of an epidemical disease, we are too apt to suppose 
that it may be successfully extended to every other variety : 
and it is from this our natural tendency to generalization, 
that so many and opposite measures are recommended in 
some fevers which bear the same name, but which have such 
diversities of character as to demand different plans of cure 
at different times. In many instances of the measles, great 
care is even required to regulate the temperature of the 
rooms where the patients are confined ; for I have repeat- 
edly seen pulmonary inflammations follow the too liberal 
admission of cold air, where the skin was morbidly sensi- 
ble to the variations of the surrounding atmosphere. We 
must, then, act with becoming caution in respect to advis- 
ing any measure which makes a powerful impression on the 
surface ; and when we find the sick complaining of chilli- 
ness in an ordinary temperature, we should not ever, em- 
ploy the tepid, much less the cold affusion. Indeed, hav- 
ing in no instance dared to use the latter, I am totally in- 
competent to give an opinion respecting the circumstances 
under which it ought to be recommended ; but reasoning 
from the analogy of the influence of cold air, I am natur- 
ally led to infer, that its use will be found very limited in 

27* 



210 MEASLES. 

this disease. It must not, however, be presumed from the 
tenor of these remarks, that I am_adverse to ventilation in 
the measles ; on the contrary, 1 think it highly beneficial, 
when properly conducted during the eruptive fever ; being 
fully satisfied, that if a cold atmosphere is often hazardous, 
a close stifling one is equally, if not more so, in every va- 
riety. All the cases of measles which I have seen attend- 
ed with dark petechiae and hemorrhages in the last stage, 
had been confined in heated and ill ventilated apartments 
in the first ; and it is somewhat remarkable, that though 1 
examined two cases of this nature, where there had been 
copious discharges of black blood by stool, I found no co- 
agula in the intestines, but slight traces of inflammation of 
the villous coat in one, and none in the other. So far as 
my observation has extended, I should decidedly say, that a 
large, airy chamber is in general best for rubeolous patients : 
though at the same time, that the temperature should be 
as equably regulated as possible, between the ranges of 50° 
and 60° of Fahrenheit's scale. That in the main a mod- 
erate degree of warmth is most favourable to the measles, 
would sufficiently appear from their generally being less 
severe in mild than in cold weather, and surely this well- 
known fact should teach us to surround our patients with 
an agreeable temperature, rather approaching to that of 
our summer than of any other season. By way of more 
effectually guarding against sudden impressions on the sur- 
face, aperient medicines ought commonly to be given early 
in the morning, that they may operate before bed-time ; for 
When a child is disturbed by the operation during the night, 
particularly in the spring or winter, he is more apt to re- 
ceive cold in this disease, than during the day, when the 
chamber is usually of a more congenial temperature.. In- 
deed, at all times during the action of purgatives, we should 
be cautious in exposing the surface, and therefore the use 
of a bed pan is frequently requisite : but such wariness is 
unnecessary in the simple and inflammatory scarlatina, the 
subjects of which bear the application of cold air to the 
skin, not only without prejudice, but with advantage in the 
height of fever. Some practitioners of my acquaintance 
are very partial to the use of the carbonate of ammonia in 
the simple cases of the measles, and give it both during 
and after the eruptive fever, by way of determining the 
blood to the surface ; and when there were no decided ev- 



MEASLES, 211 

idences of inflammation, I have certainly seen it useful on 
some occasions by creating a gentle perspiration, while the 
patient was kept in a regulated temperature. 

Nor is it during the eruptive fever only, that we have to 
guard against too low or too variable a temperature ; for 
the greatest attention is required in that respect when the 
rash fades away. Most of the inflammatory affections which 
follow the measles arise from imprudent exposures to cold : 
and therefore I am fully confident, that many children might 
be saved by confining them within doors, and by clothing 
them properly for some time after that complaint has dis- 
appeared. These precautions should always be adopted 
in the winter and spring. Even in summer, convalescents 
should only be allowed to go abroad in the middle of fine 
days, and not without some additional apparel. It has been 
well remarked, that more skill is shown in curing, but more 
wisdom in preventing a distemper ;* and it were to be wish- 
ed, that medical men would constantly bear this maxim in 
their recollection, for the benefit of those prone to disor- 
ders. After every febrile disease, the body is left weaker 
than before the attack : in proportion to this weakness it 
becomes the more incompetent to resist impressions inter- 
nal as well as external ; and the impressions themselves 
have an additional power from the highly susceptible state 
of the capillary arteries. But if in combination with the 
universal weakness, and with the preternatural susceptibil- 
ity of the capillaries, a decided predisposition to disease 
should any where prevail, whatever communicates a gene- 
ral shock to the system may convert the predisposition into 
actual disease ; and the disease will be seated in that organ 
where the predisposition existed in the greatest force before 
the communication of the general shock. Now it has been 
before noticed, that the pulmonary organs are more partic- 
ularly affected in the measles than other internal parts ; and 
hence we more frequently find the predisposition engender- 
ed in them, which is converted into inflammation when cold 
is applied after the retrocession of the rash. Nevertheless, 
the lungs are not the only internal organs which are liable 
to suffer during the developement and rise of the fever, since 

* Fruits of Solitude, in Reflections and Maxims relating* to the Con- 
duct of Human Life. By William Penn. See a new edition, p. 52. 
London: printed for James Philips, George- Yard, Lombard- Street, 
1793. 



212 MEASLES. 

we often have evidences of something morbid in the hepa- 
tic and intestinal secretions ; and hence a diarrhoea is apt t6 
arise afterwards, which Sydenham supposed to proceed 
from a flux of the peccant effluvia on the lining of the bowels, 
but which is almost always connected with increased ac- 
tion of the liver, as well as of the villous coat of the intes- 
tines. The brain is sometimes unusually affected in the 
beginning of the measles : and though the free eruption on 
the surface generally suffices to remove that affection, yet 
it sometimes leaves a tendency to, and is followed by the 
complaint called hydrocephalus, as shall elsewhere be more 
distinctly noticed. If we turn from the interior to the sur- 
face of the body, the skin and the eyes appear to participate 
largely in the morbid actions of the measles, but the skin in 
particular, over which the disease may be said to be diffu- 
sed, and upon which its main force is spent in the simpler 
attacks ; and hence, too, originate the predisposition to dis- 
ease in both these organs, which are so often attacked with 
inflammatory disorders, when the eruption has abated. It 
is not, however, the influence of cold alone that may pro- 
duce any of the affections above mentioned, after the ter- 
mination of the measles ; for an improper diet, or stimula- 
ting drinks, may create an universal excitement, and that 
again so re-act on latent and local predispositions, as to pro- 
duce acute, sub-acute, or chronic inflammations. In anoth- 
er place, I endeavoured to expose the inconsistency and 
danger of allowing too generous a regimen to those conva- 
lescent from fevers ; and I must here repeat, that it should 
be our object to restore the powers of the system gradually, 
by a light and cooling diet. If we attempt to communicate 
strength at once, we not only defeat the end in view, but 
risk the life or the health of the patient ; for if an obvious 
inflammation of the viscera should not thereby supervene, 
an obscure one may, and cause months or years of suspense 
and suffering. So far from rich food and stimulating drinks 
being requisite during the convalescence of young or natu- 
rally robust subjects, evacuations by purgatives are frequent- 
ly required to restrain the excitement, which naturally suc- 
ceeds the stage of collapse ; and it ought to be our business 
daily, for some time after the subsidence of the original fe- 
ver, to regulate the returning tide of the arterial s)stem, 
that it may not pass the boundaries of health, and become 



MEASLES. 213 

the occasion of disease. Besides, if we load the stomach 
with improper articles of diet during convalescence, we are 
almost certain to produce disorders of the digestive organs ; 
and these again create nervous irritation, which, in its turn, 
leads to vascular excitement, general as well as local, and 
thus trains of morbid actions may follow each other, partic- 
ularly in weak organs. 

From the foregoing hints, then, it would appear, that in- 
flammatory attacks are liable to take place internally as 
well as externally, after the measles themselves have entire- 
ly subsided. When any part of the lungs is the seat of in- 
flammation, the treatment already laid down must be pursu- 
ed according to the nature of the inflammation, and to the 
age of the patient. Nor must we fail under these circum- 
stances to make due allowances for whatever degree of de- 
bility may have been induced by the prior excitement of 
the eruptive fever ; and if the symptoms should have run 
so high, during the continuance of that fever, as to demand 
the lancet, the depletion must be still more cautiously j ro- 
portioned to the powers of the patient when inflammation 
again occurs, after the disappearance of the eruption. In 
subjects who have been much emaciated by the measles, 
and who are afterwards afflicted with visceral inflammation, 
considerable care is often required as to the applications of 
blisters ; for the blistered portion of the skin is sometimes 
liable to run rapidly into gangrene, or else it becomes a 
sloughy sore, which is very difficult to heal, and which occa- 
sions an excessive irritation. The skin is one of the prin- 
cipal seats of the measles. It is exceedingly stimulated du- 
ring the eruptive fever, and suffers a correspondent loss of 
tone as that fever declines ; and as this cutaneous debility- 
is greatest in emaciated or in broken-up habits, so the sur- 
face in them is less able to resist inflammation, without end- 
ing in gangrene, or in an ill-conditioned sore. This pecu- 
liar state of the skin is sometimes connected with derange- 
ment in the digestive functions, which ought always to be 
strictly attended to after the subsidence of every febrile dis- 
ease. But where a tolerable degree of constitutional vigour 
remains after the abatement of the measles, we need have 
no dread of applying blisters when a visceral inflammation 
occurs; for then they rarely product >ore, and 

when they do, the general system does not suffer so much 



214 MEASLES. 

from the irritation of it, as to counterbalance the local ad- 
vantages. In cases of this nature, the blistered part should 
occasionally be washed with a weak solution of the sulphate 
of zinc, or an aqueous one of opium, and generally djessed 
with the common brown cerate : but when the pain is ex- 
tremely great, a poultice often gives considerable relief, and 
gentle purgatives, followed by small opiates, will always be 
beneficial. When a diarrhoea arises after the fading of the 
rash, it ought never to be restrained by astringents, for it is 
an effort of nature to carry off an inflammatory excitement 
of the abdominal viscera, and of the general habit. The 
symptoms of abdominal inflammation have been sometimes 
so distinct in this sort of diarrhoea, that I have ordered ven- 
esection, and with the most striking benefit ; but in a large 
majority of examples, I have found nothing more requisite 
than a dose of calomel or castor oil now and then, with mu- 
cilaginous drinks, and a small opiate, or the warm bath, oc- 
casionally to allay irritation. For my own part I must con- 
fess, that, partial as I am to calomel in febrile and inflam- 
matory complaints, I do not like to exhibit it largely or re- 
peatedly when the system has been raised from a state of 
collapse into a second excitement ; for in that case an unu- 
sual degree of nervous irritation mostly exists, which is of- 
ten much aggravated by the too free exhibition of calomel, 
especially if it be pushed on to ptyalism. Yet when the na- 
ture of the stools indicate a decided disorder of the hepatic 
secretions in the diarrhoea in question, an occasional dose of 
calomel or df the blue pill will always do good ; while the 
daily perseverance in moderate doses of castor oil will hard- 
ly ever fail to restore them to a natural condition. Some- 
times in this diarrhoea there is a superabundance of acid in 
the primae viae, evinced by the green sour evacuations ; and 
whenever this occurs, a little of Henry's magnesia will most 
commonly answer an excellent purpose. This preparation 
is certainly preferable to the calcined magnesia which is 
usually sold in the shops ; but it is to be lamented that a 
philosopher should not be philanthropist enough to prefer 
the public to his private interest. In a word, I could wish 
that this enlightened and excellent chemist would favour the 
world with the mode of preparing his magnesia. From 
some experiments which I have made, I suspect, that it is 
prepared by passing the common magnesia, mixed in water. 



MEASLES. 216 

through gauze, cotton cloth, or like substances ; at least I 
have obtained some this way which seemed nearly as soft, 
and which operated as well. The superiority of Henry's 
magnesia over the common most probably consists in its be- 
ing reduced to a finer powder. For we well know, that 
rhubarb, jalap, and other ingredients, operate more easily 
and perfectly the more minutely we can divide their consti- 
tuent particles : and of this we have a striking example in 
the compound powder of jalap, which on account of its in- 
timate union and extreme divisibility, acts more agreeably 
than either the ordinary jalap, or the super-tartrate of pot- 
ass given alone. But, in returning from this digression, it 
may be proper to observe, that when a diarrhoea does not 
follow the decline of the measles, a lax state of the bowels 
should always be instituted : and this, with warm clothing, 
a cooling diet, avoidance of cold, and the occasional use of 
the tepid bath, will generally prevent inflammatory attacks 
©n the vital organs. Mead says, that by bleeding at the end 
of the disease, w r hen the skin is growing dry, and the scales 
falling off, we may prevent a flux of humours upon the breast 
and intestines, and the symptoms of hectic fever and con- 
sumption 5* but though bleeding may be, and sometimes is 
necessary at that period, yet there can be little doubt but 
this excellent author was too fond of the remedy in the mea- 
sles, and what he has here said with regard to venesection, 
is more justly and generally applicable to purgatives, and 
a spare, liquid diet. 

It is a remarkable fact, that when any cutaneous affec- 
tions arise after the measles, the internal organs generally 
remain free from disease ; and even where some internal 
disorder has existed, I have not unfrequently seen it disap- 
pear on the occurrence of some spontaneous eruption of 
the skin. Indeed, there are many cases of this nature alrea- 
dy on record. At all times we should, therefore, be most 
wary in meddling with vesicles, pustules, boils, and the like, 
when they come out after the measles ; for although they 
may be temporary blemishes on the surface, they are often 
the occasions of saving the vital works within. We most 
frequently ought to allow such affections to run their natural 
course, and cold external applications and drastic purgatives 
ought at least always to be avoided ; as the first as well a? 

% See rah ii, p. 152, of the edition of Me ad's Works, before quoted 



216 MEASLES. 

the last sometimes suddenly repel them, and an increased 
action in some of the viscera succeeds. Yet when they 
prove troublesome from too long a continuance, or where 
they proceed from some disorder of the digestive organs, 
the warm bath, and the moderate administration of the 
Harrogate sulphureous water will remove them with the 
greatest safety ; and I have found these two expedients also 
of most advantage in those chronic, glandular complaints, 
which sometimes follow this distemper, and which are 
sometimes connected with a vitiated state of the abdominal 
secretions. There can be no doubt that gangrenous affec- 
tions of the skin occasionally arise after the subsidence of 
the measles, especially in strumous habits, and in children 
who have been confined in ill ventilated apartments. Sev- 
eral instances of this sort might be cited from respectable 
authorities, but not many have fallen under my own obser- 
vation, and the last which I saw occurred under the lower 
jaw, in a recent epidemic. When ophthalmia supervenes, 
it is sometimes extremely urgent, and ought in general to 
be treated promptly, by bleeding, purgatives, and blistering. 
This plan will frequently arrest the disease at once, or at 
all events may prevent it from assuming a chronic character; 
but where the lining of the palpebrse is loaded with blood, 
the under one in each eye may often be scarified with im- 
mediate and great benefit. If, however, a proper attention 
be paid to the preventive measures before recommended, 
the measles will seldom be followed by any of those inflam- 
matory complaints which the vulgar emphatically call the 
dregs of the disease. And where there is any known or sus- 
pected tendency to pulmonary disorders, a preventive regi- 
men should be the more rigorously enforced ; for independ- 
ently of those already poihted out, there are some obscure 
affections of the lungs, which are apt to be engendered af- 
ter the decline of the rash, from the influence of cold and 
other causes. The general scheme of this work will only 
allow me briefly to advert to such affections under the head 
of pulmonary consumption : and even then it will be neces- 
sary to embrace some points not strictly relevant to the se- 
condary effects of the measles ; but these may be excused 
from the nature of the subject, to illustrate which require* 
the lights of collateral circumstances. 



BALSAM OF COPAIVA. 






BALSAM OF COPAIVA. 



A.LL the outlets of the body are covered with a mem- 
brane, which in a state of health secretes mucus for their 
lubrication ; but when this membrane is inflamed or irritat- 
ed, the natural secretion is always increased, commonly 
vitiated, and often purulent. Mr. John Hunter has asserted, 
that the discovery of mucus and other membranes secreting 
pus from mere inflammation was first made by his brother 
Dr. William Hunter, and by Mr. Sharp; while Dr. F. Swedi- 
aur affirms that Morgagni and De Haen made this discovery 
several years before our justly celebrated countryman. 
But this is a matter of little consequence, since nothing is 
more common in science than for men to make similar dis- 
coveries or inventions, who had no intercourse with each 
other 5 and it is enough for my present purpose to point 
out the known and acknowledged fact, that inflamed mu- 
cous membranes may and do secrete pus witout actual 
ulceration. Having spoken of the efficacy of copaiva in 
chronic inflammations of the trachea and its branches, it 
will hardly be thought a digression if I state its striking 
utility in gonorrhoea, which is an affection of a mucous 
membrane, and if I also suggest its application in other 
diseases. 

There are two species of gonorrhoeas — the specific and 
the non-specific. The specific proceeds from a peculiar 
virus, and propagates itself to second persons indefinitely ; 
the non-specific originates from strictures, irritable urethras, 
the contact of leucorrhoeal or menstrual discharges, or from 
instestinal and other disorders, and it cannot becommunicat- 
ted to second persons. It is not mydesign to describe their 
characters, but the above distinction merits our attention 
both in a medical and moral sense ; for the judgment of the 



4 BALSAM OF COPAIVA. 

practitioner, and the reputation of the patient, might equally 
suffer from confounding the specific with the non-specific. 
The following observations principally relate to the specific 
or virulent gonorrhoea, though the remedy which it is my in- 
tention to advise, will be found more or less efficacious in eve- 
ry variety of this complaint occurring in males. The late 
Mr^ John Hunter thought, that what is called the virulent 
gonorrhoea, was scarcely ever retarded by artificial means ; 
and an intelligent writer, Mr. Samuel Cooper, has more 
recently observed, that as we have no appropriate remedy 
for this disease, it is fortunate time alone will effect the 
cure. An experienced practitioner, who had seen nume- 
rous cases of the specific or virulent gonorrhoea, once told 
me, that he had never known its duration shortened by 
medicine; and that from first to last, he usually found it 
to contiuue about six weeks. Indeed many medical men 
suppose this affection to preserve a determined character 
and course, in defiance of every measure ; and there are 
perhaps few who attempt, in the first stage, any thing more 
than to alleviate the inflammatory symptoms by evacuations, 
rest, and an antiphlogistic regimen. An old author, Dr. 
Samuel Turner, says that copaiva is a " noble medicament 
in finishing the cure of claps and'of gleets ;" and from his 
to the present time it has been so generally restricted to 
the advanced stages, that, so far as I know, there is only 
one writer who advises it, and that by a short paragraph, 
in the first or inflammatory stage. But in recommending 
it as generally a speedy and an effectual curative in the 
primary as well as in the last stage of gonorrhoea, I must 
advert to the source whence my information was first de- 
rived on this subject. Some time ago, Dr. Pearson Daw- 
son mentioned to me, that he had prescribed copaiva, with 
signal success, for more than twelve years, in the very 
commencement of the virulent gonorrhoea. As the opin- 
ion of this enlightened physician had been drawn from 
close observation and extensive experience, it at once 
determined me to try the medicine ; and I can now confirm 
its efficacy in gonorrhoea, not only from cases which have 
fallen under my own observation, but also from the prac- 
tice of an intelligent surgeon, to whom Dr. Pearson Daw- 
son made a similar communication. My investigations 
might lead me to infer, that copaiva, properly and purely 



BALSAM OF COPAIVA. 5 

administered, would not fail once in twenty times com- 
pletely to arrest the progress of this disease ; an inference, 
however, which must be limited to the male, as it is not so 
efficacious in the female gonorrhoea, though even in the 
latter it is superior to every other drug, in conjunction with 
cleanliness and injections. The copaiva will sometimes • 
cure an incipient gonorrhoea in two, three, or four days. 
provided the symptoms be not violent ; and in the worst 
cases it will generally succeed within the first two weeks. 
But that practitioners may not be disappointed in their 
future trials of this medicine, they must be mindful to pro- 
cure it genuine, to administer it in proper form and doses, 
and to continue it regularly for a sufficient length of time. 
As its failure will most frequently arise from inattention to 
the one or to the other of these circumstances, some special 
allusions to them may not be superfluous. 

Copaiva is improperly denominated a balsam, since it 
contains no benzoic acid, but consists of resin and essential 
oil. It is insoluble, in water, but soluble in ten parts of 
alcohol; and the best is said to come from the Brazils. Its 
smell is fragrant, but its taste somewhat bitter and disagree- 
able ; it is usually of the consistence of oil, and in colour 
and transparency not unlike fine rum ; but when very 
long kept, it grows almost as thick as honey, though it does 
not become dry or solid, like most other resinous juices. 
Nevertheless, its efficacy is much impaired by long keeping, 
and therefore it should always be obtained as fresh as possi- 
ble. The spurious or adulterated copaiva is not transpar- 
ent, it frequently has some turbid watery liquor in it, and 
a much less agreeable smell than the genuine. It has been 
acknowledged by druggists to a friend, that it is not unusual 
to adulterate copaiva with common oil, with Venice tur- 
pentine, or with Canadian balsam ; and this fact affords an 
additional reason for care in its selection, since, unless it be 
pure, it will only disappoint the practitioner and disgust 
the patient, as well in gonorrhoea as in other complaints. 
Even when pure, copaiva is apt to disagree with the stom- 
ach, sometimes inducing nausea, retching, vomiting, or disa- 
greeable eructations. It imparts to the urine a bitter taste, 
and a peculiar smell, but not of the violet kind, like the 
turpentines. In moderate doses it is a mild laxative, in 
large ones it often occasions copious and fluid discharges of 



6 BALSAM OF COPAIVA. 

fecal matter, but generally without uneasiness. When 
exhibited in excessive doses, it may excite a sort of vibra- 
tory feeling in the brain, or cause a febrile anxiety, with a 
mental disturbance bordering on delirium. When it disor- 
ders the stomach much, its exhibition is sometimes followed 
by an eruption resembling the nettle-rash ; and in a few 
peculiar habits I have seen this eruption arise where little 
or no affection of the stomach apparently existed. 

In all the varieties of gonorrhoea, copaiva increases the 
quantity of urine, but almost always with a soothing effect. 
As its powers may be much impaired by improper combin- 
ations, it should usually be blended in soft distilled water, 
with mucilage of gum arabic, or with the yolk of a newly- 
laid egg. The following formula in general answers very 
well in gonorrhoea. Take about a hundred, or a hundred 
and twenty drops of copaiva, rather less than two ounces 
of mucilage, two ounces of soft distilled water, and two 
drachms of refined sugar. The copaiva and the mucilage 
must first be most intimately rubbed together in a marble 
mortar: the sugar must afterwards be dissolved separately 
in the water; and then these two mixtures must be well 
incorporated, by small portions at a time, until an entirely 
smooth and uniform emulsion be made. One half of this 
emulsion is to be taken immediately before breakfast, and the 
other half immediately before supper. This mode of admin- 
istering copaiva not only assists its efficacy on the principle 
of minute divisibility, but it also greatly obviates its un- 
pleasant effects upon the stomach by becoming assimilated 
with the food. It is, however, most frequently advisable 
to eat a small aromatic spice- nut before and after each 
dose, and one or two during the day, more effectually to 
guard against disturbance of the stomach ; and in some in- 
stances it will be requisite to compound the mixture with 
an aromatic water, and to add a very few drops of alcohol, 
both of which render it less liable to excite nausea or eruc- 
tations. Sometimes, however, the copaiva agrees best 
with the stomach when given in drops upon cold water ; 
and wherever it sickens much with the mucilage, this meth- 
od should therefore be tried. On some occasions, the do- 
ses of copaiva will have to be increased to the amount of 
three, four, or five drachms in the twenty-four hours : but 



BALSAM OF COPAIVA. 7 

the smallest dose should be first tried, and where that fails, 
it may be gradually augmented until it answers its specific 
purpose ; and wherever it is necessary to give this drug in 
larger quantities, the dose should rather be given at three 
or four intervals, than twice in the day. The first two do- 
ses of the emulsion above-mentioned will frequently lessen 
the ardor urinae, the discharge, and the chordee ; while a 
regular perseverance in the medicine will rarely fail rapid- 
ly to remove every trace of the disease. But it must be 
remembered, whether the gonorrhoea be virulent or the 
contrary, slight or severe ; whether the cure be accom- 
plished in three days or in a fortnight ; that the copaiva 
must be regularly administered for about a week or ten 
days afterwards, otherwise a relapse for the most part may 
be confidently anticipated. 

When ardor unrinae exists to any extent in gonorrhoea, it 
is generally better to allow the copaiva to act with tolera- 
ble freedom on the bowels ; but when it proves trouble- 
some or inconvenient as a purgative, a few drops of lau- 
danum may be advantageously combined with each dose. 
The addition of laudanum, indeed, is sometimes very ben- 
eficial, in mitigating both the local and the general irrita- 
tion. Cases may occur, where the inflammatory symp- 
toms run very high in the onset, which require general and 
local blood-letting with other evacuations, before the ad- 
ministration of the copaiva ; but I am fully persuaded that 
such cases will be found rare, and that in general it will on- 
ly be necessary to assist it by an occasional dose of opium. 
At the same time, an abstemious diet, rest, and strict clean- 
liness, will always tend to favour the efficacy of this medi- 
cine 5 whereas a directly opposite effect will result from 
stimulants, exercise, and other irregularities of regimen. 
The simple treatment here laid down being adequate for 
the cure of the male gonorrhoea, it removes every plea for 
the use of astringent injections ; a practice which, in men. 
cannot be too strongly condemned, because it is so fre- 
quently adopted, and because it is so apt to produce pain- 
ful stranguries, confirmed gleets, or strictures of the ure- 
thra. 

From the remarkable efficacy of copaiva in an acute in- 
flammati on of one membrane, we might ask, has it a similar 
power over a similar affection of every mucous membrane I 



8 BALSAM OF COPAIVA » 

This question naturally arises out of that disposition to 
generalize, which is inherent in every mind, and which has 
led to the discovery of important truths, as well m medi- 
cine as in other sciences : but to infer at once from a par- 
ticular fact, that copaiva must necessarily be efficacious in 
inflammation of every mucous membrane, would be one of 
those rash and blind conjectures, which have too frequent- 
ly disgraced and retarded physic. Yet at the same time, 
the certainty of this very fact is calculated to make us turn 
our inquiries to the ascertainment of the general agency of 
copaiva in inflammations of mucous membranes ; and as 
other facts have been previously adduced to show that it 
has an actual influence over certain inflammations of the 
mucous membrane of the trachea and its branches, the rea- 
sonableness of such inquiries becomes forcibly apparent, 
Having chiefly trusted in all acute inflammations of vital 
parts to the lancet, purgatives, mercurials, blisters, and 
opium, 1 cannot pretend to specify what may be the effect 
of copaiva in some of those inflammations; but as its use is 
not incompatible with the active and indispensable means 
here mentioned, there are obviously some affections in 
„ which it may deserve a trial, -Since, if it were even useless, 
it could not possibly do any harm. 

In that violent disease the croup, the mucous membrane 
of the trachea is invariably more or less inflamed ; and not- 
withstanding the prompt employment of blood-letting, emet- 
ics, purgatives, mercurials, and blisters, it sometimes proves 
mortal; and therefore in certain modifications of this dis- 
ease, might not the copayia be an useful auxiliary to those 
remedies on which most reliance is general^ placed ? In 
spasmodic asthma and hooping cough, the*rnucous mem- 
brane of the trachea or of the bronchia is generally im- 
plicated in the morbid phenomena ; and as I have seen 
great relief obtained in some cases from the copavia, it is a 
desideratum to ascertain its operation more perfectly in 
these complaints. In dysentery, the mucous membrane of 
the bowels is affected, and on this account might not co- 
paiva be beneficial, but more especially in those protracted 
dysenteries which usually baffle the ordinary means ? Yet 
in the acute and sub-acute dysenteries, the hepatic and cu- 
taneous functions are always disturbed, and the early use 
of the lancet, with the prompt and powerful exhibition of 



BALSAM OF COPAIVA. 9 

calomel, must always constitute our main expedients ; and 
whatever other means we employ, they are only to be ac- 
counted secondary at best, but among these secondary 
means perhaps copaiva may hereafter be placed. As the 
chronic dysentery, however, is generally attended with ul- 
cerations of the lining of some part of the intestines, might 
not the copaiva prove a suitable laxative, and also a saluta- 
ry stimulus to the ulcers themselves? In three obscure 
cases, where matter was passed from the intestines, it ap- 
peared to me of considerable service, though in a fourth it 
gave no alleviation whatever. As some of the older writers 
have recommended it in dysenteries and similar affec- 
tions of the belly, we have been perhaps too hasty in dis- 
carding its use in modern times. What has been called the 
schirro-contracted rectum, if my observation be correct, is 
always connected, in its commencement, with a torpid 
state of the bowels ; and it has appeared to me to occur 
more frequently in women than in men, the habits of the 
former predisposing them to constipation. In its onset it 
is frequently necessary to attend to the state of the liver, 
since maintaining a natural secretion of bile, and a regular 
action on the bowels, wiil sometimes afford the chance of 
success, provided this plan be early commenced in combi-" 
nation with small general, or free topical blood Jetting, and 
an antiphlogistic regimen. Even when the torpidity of the 
bowels is not dependent on a deficiency or a depravation 
of bile, still the same course will generally be among the 
best that can be pursued. Now as in this disease of the 
rectum, patients declare themselves to be easiest when 
their motions can be made liquid, and as copaiva produces 
that effect, is it not likely to be of somq utrlity ? Besides, 
as it has a specific operation on the mucous membrane of the 
bowels, shown by the nature of the motions, might it in any 
degree contribute to induce a favourable change of action 
on the morbid part itself? Small tumors sometimes form 
on the villous coat of the intestines, near the extremity of 
the rectum, which occasion a great deal of suffering, and 
which if neglected often occasion an irremediable disease 
of the gut; but they ought always to be speedily removed, 
not by the ligature but by the knife, and then patients will 
frequently regain their health, if long rest, laxatives, and a 
spare diet, be enjoined after the operation. In two or 

B 



10 BALSAM OF COPAIVA. 

three cases I have known some practitioners pronounce 
the existence of a stricture in the rectum from not having 
been able to force the sphincter freely with the finger ; and 
yet on the exhibition of a few doses of castor oil, the fin- 
ger has passed readily, and not the slightest vestige of ob- 
struction remained. The fact is, that retention of scybala 
in the colon will often produce this sort of temporary spas- 
modic state of the sphincter; and as it may easily be a 
cause of deception, practitioners should always make a 
point of having the bowels properly evacuated before they 
venture upon a decided opinion in certain diseases of the 
rectum. But these remarks are leading me too far from 
the original subject of discussion. 

In regard to chronic diseases, copaiva has had different 
virtues attributed to it by different individuals, but nearly 
all concur in its being generally beneficial in gleets, and in 
leucorrhoeas ; indeed in the former of these it seldom fails, 
under the directions already noticed in gonorrhoea, as to 
formula, perseverance, and temperance. By some it has 
been said to give tone to the nervous system, to cleanse 
and heal exulcerations of the urinary passages, and even 
to be serviceable as an external vulnerary ; whilst others 
have affirmed it to be efficacious in diseases of the lungs, 
in hemorrhoids, in hectic fever, and in many complaints 
beside. So general an influence having been ascribed to 
it, has probably been the cause of the neglect into which it 
has fallen amongst modern practitioners : but as its power 
over gonorrhoea is so decided, and as it is considerable in 
some affections of the windpipe, we have at least grounds 
for supposing that it may be successfully employed in other 
diseases ; and what some of those diseases probably are I 
have endeavoured to point out, that the consideration of 
their cure may still be prosecuted. The more we inquire 
into the modes in which medicines act, the more we shall 
be satisfied, that many of them operate through the medi- 
um of the circulation ; and as they may thus be conveyed to 
every quarter of the body, and as copaiva has the power of 
changing morbid states of some mucous membranes, it may 
possibly exert a similar effect on others. Still further to 
show that its operation is neither limited to the mucous 
membrane of the urethra, nor to that of the windpipe, I 
have known it very beneficial in some cases of leucorrhcea. 



BALSAM OF COPAIVA. n 

a disease immediately seated in the mucous membrane of 
the vagina. It is, however, in simple leucorrhoea only, 
that we must look for it to be at all efficient, and even in 
that it should not supersede the use of injections ; but when 
leucorrhoea is complicated with affections of the uterus and 
its appendages, it cannot be expected to succeed. As 
chronic defluxions of the mucous membrane of the trachea 
or of the bronchia are likewise sometimes combined with 
organic disease, so it will sometimes completely fail in 
them ; though, upon the whole, it will generally give more 
relief than most other medicines in those catarrhal deflux- 
ions, which are frequently so troublesome, if not so dan- 
gerous to old people. What I have actually observed of the 
effects of this medicine in some diseases must be carefully 
separated from what I have suggested with respect to its 
probable utility in other diseases ; and since it is most fre- 
quently mild in its operation, the few facts and hints here 
adduced may not only lead others to investigate the prop- 
erties of copaiva with more accuracy, but likewise to ex- 
plore those of the whole class of balsamic and resinous 
medicines, but especially of turpentine, which may be 
found of considerable efficacy. To borrow an expression 
of Lord Bacon, it cannot be doubted, that there are yet 
many things of excellent use to be discovered in the bo- 
som of nature. A wide field of investigation is presented 
to us, not in the vegetable only, but also in the mineral 
world ; and probably some agents will hereafter be suc- 
cessfully applied, the efficacy of which is not so much as 
conjectured at present. The distinguished individual just 
named, thought that ih^number of specifics might be great- 
ly increased by dilfgent investigation ; and when we con- 
sider the known powers of some medicines, which act on 
particular parts of the body, we need not despair of finally 
realizing his enlarged anticipations. Nor can it fail to ex- 
alt our opinion, and to stimulate our inquiries respecting 
remedies, when we adduce the efficacy of those actually 
prepared and presented by nature ; and such are the sul- 
phureous waters of this country, which will be acknowl- 
edged, upon a more extensive trial, to deserve very high 
commendations. 



CHRONIC DISEASES, 



AND 



SULPHUREOUS WATERS. 



CHRONIC DISEASES, 

AND 

SULPHUREOUS WATERS. 



f F any one were to assert, in unqualified terms, that med- 
icine is a conjectural and vague art, it were easy to refute 
him, by proving its great certainty in many acute diseases ; 
and if any one were to ask what part of physic is most 
defective, we might point out chronic diseases, since in 
them our efforts have hitherto been the most ineffectual. It 
is for want of having discriminated the general difference of 
result in the treatment of acute and chronic diseases, that 
some have so much underrated, and others so much orver- 
rated, the powers of the medical art. Speak of acute dis- 
eases, and we may justly maintain the present utility of 
our profession ; speak of chronic diseases, and we must 
with regret confess its present imperfection. If any prac- 
titioner should be generally unsuccessful in the treatment 
of acute diseases, the fault must be his own, provided he 
be consulted in the earliest stages : for the united agencies 
of blood-letting, purgatives, mercurials, opium, and blis- 
ters, will commonly control the very elements of these 
diseases, when opportunely and judiciously directed ; and 
if any one will still be so stubborn as to reject the use of 
some of the most powerful instruments which we possess, 
the failures are rather to be attributed to himself, than to 
the inefficiency of medical expedients. As we cannot 
make such a confident declaration as to chronic diseases, 
though we can often palliate and sometimes cure them, we 
are constrained to acknowledge, either that their nature is 
more irremediable, or that the means employed are less 
efficacious. Both these inferences are in some measure 



16 CHRONIC DISEASES, 

true. Upon the whole, chronic diseases are really less 
manageable than acute ones, because in the former the 
morbid states are slowly produced, and cannot therefore 
be speedily changed ; whereas in the latter the morbid 
states are quickly produced, and not having acquired 
strength from continuance, may usually be quickly changed. 
The means which we administer in chronic diseases are 
numerous, but most of them ambiguous, and questionable 
at the best ; whereas in acute diseases, our means are few^ 
and their operation plain and indisputable. The long 
catalogue of prescriptions for chronic diseases at once in- 
dicates, that all is not right in our pathology, as it implies 
that each prescription is liable to fail, and that the whole 
may be successively required. Wherever we have any 
thing like principles to guide us, our prescriptions are ex- 
tremely limited ; wherever we have no fixed principles to 
guide us, our prescriptions accumulate with empirical ra- 
pidity. But what, it may be reasonably inquired, is the 
principal cause of all this complexity of formulae in chronic 
diseases ? Undoubtedly it arises from that vagueness of 
opinion which exists respecting the nature of these diseas- 
es in their onset, and in the greater part of their progress ; 
and so long as we attempt to cover our ignorance by 
such terms as nervous, billious, dyspeptic, spasmodic, and 
the like, so long shall our practice be mere experiment in 
most chronic affections. We may make a sort of drug- 
gist's shop of the stomach of every patient labouring un- 
der chronic disease, by alternately cramming it with most 
of the articles of the pharmacopoeias ; but we shall not, 
probably, advance in the treatment, until we deduce pa- 
thological principles, from cautiously marking the rise and 
progress of the symptoms, and exploring their seats and 
effects. For several years past, it has been part of my 
employment to collect facts on chronic diseases, and as the 
inquiry will not be completed for many years to come, in 
the mean time I offer a few brief results of my observation 
*and experience in regard to them. 

Between chronic and acute diseases, a much nearer 
affinity perhaps exists, than has usually been conjectured. 
The first stages of both consist in disordered action, the last 
generally in deranged structure. If high degrees of venous 
or of arterial fulness mark acute diseases, low degrees of 



AND SULPHUREOUS WATERS. 27 

the same conditions mark chronic diseases : in reality 
these degrees may mutually pass into each other, so that 
an acute disease shall become chronic, or a chronic disease 
shall assumean acute character; and whoeverhas accurately 
marked the progress of the symptoms will be especial- 
ly satisfied, that few chronic diseases exist without the 
supervention of an attack more or less acute. Though 
chronic congestion of the veins, and chronic excitement of 
the arteries, will not account for all the varied phnomena 
of chronic diseases, yet as the one or the other of these 
states is almost invariably present in such affections, and 
forms a material part of their pathology, a few pages shall 
be dedicated to the consideration of each. 

Chronic congestion of the veins generally occurs in the 
brain, in the liver, in the spleen, or in the vicinity of the 
heart. If this species of congestion be in the brain, un- 
easiness of some sort almost invariably exists in the head, 
with more or less of disturbance in some of the external 
senses; and the periods of watching and of sleep become 
less statedly regular than they were in health. Languor 
of body and mind is mostly present, so that the patient 
can neither employ the one nor exercise the other so agree- 
ably as before ; and in some individuals a forgetfulness of 
recent transactions is observable, whilst in others a change 
in the general manner indicates the influence of the disease 
on the mental operations. The face as well as the whole 
surface is for the most part pale, and the pulse languid or 
oppressed ; both of which symptoms are dependent upon 
that diminution of arterial tone, which accompanies chro- 
nic diseases of venous congestion, so long as they strictly 
deserve that denomination. The heat of the skin is mostly 
somewhat below the natural standard, or it varies in the 
course of the day, frequently being lower in the mornings, 
and higher in the evenings ; but the patients are usually 
very susceptible of the impressions of a cool atmosphere, 
or at least they cannot bear the vicissitudes of the weather 
go well as formerly. Sometimes weakness of the upper or 
lower extremities isamongstthe primary and most prominent 
symptoms, and this may either exist with or without pain : 
but when pain does accompany the weakness, it is not often 
permanent in any place, but mostly passes from one joint 
to another. Cases of this character may be confounded 

C 



18 CHRONIC DISEASES, 

with chronic rheumatism, and they are not uncommon in 
old people. It may be laid down as an axiom in physic, 
that whenever a local defect or loss of muscular power 
cannot he accounted for by any external disorder, the cause 
is to be found in the brain or in the spinal cord. 

It very frequently happens, that chronic congestion in 
the veins of the brain is conjoined with a similar affection 
of the liver, the symptoms of which are frequently very ob- 
scure for a long time. When a sense of fulness or uneasi- 
ness occurs in the right side on motion, on pressure, or on 
turning in bed to the left side, the hepatic affection may be 
distinctly inferred ; but these symptoms are often entirely 
absent, and therefore in all cases we should inspect the 
stools, which will mostly be found somewhat of the colour of 
pipe-clay, or of the dark brown clay of which common 
bricks are made. Though no tinge of yellow may exist 
upon the skin, yet it sometimes has a dirty appearance, and 
itches a great deal, which are indications of the presence of 
bile in the secretory vessels ; upon examination, too, the 
urine will occasionally be found of a slightly bilious shade, 
as if a little saffron had been infused, and faint or small 
stains are then frequently left upon the linen of the patient, 
from the last drops in micturition. The stomach often 
sympathizes so much, that the principal mischief might 
seem seated there, when it is really in the brain or liver ; 
and in the investigation of most chronic diseases, we should 
be mindful not to mistake a sympathetic for an original dis- 
order of the stomach. It is not uncommon for practitioners 
to prescribe a longtime ineffectually, under the supposition 
that the stomach is primarily and solely affected ; and yet 
it shall at last turn out, that the disorder of that organ was 
all along secondary of some hepatic or cerebral disease. 
Many of those affections which pass under the name of hy- 
pochondriacal, hysterical, nervous, and so forth, actually 
depend upon venous congestions of the brain, or of the 
ltver ; and these are also frequently the precursors of the 
apoplectic, paralytic, maniacal, and melancholic attacks, 
which are now so common among pale or emaciated peo- 
ple. Venous congestions of the liver or brain, too, are of- 
ten separately or combinedly connected with the origin or 
advancement of cholera and chlorosis. 



AND SULPHUREOUS WATERS. 19 

The chronic venous congestions of the spleen are gene- 
rally marked by a fixed uneasiness under the ribs of the 
left side; and some cough and signs of indigestion usually 
attend it as in hepatic cases, with many of those feelings 
termed nervous. When the large veins in the vicinity of 
the heart are preternaturally loaded, palpitations with 
weight and anxiety are referred to the region of that or- 
gan ; and patients are often subject to sudden attacks of 
giddiness, of faintness, or of sickness at the stomach, while 
the pulse always shows great irregularity in the circulation. 
Indeed, chronic congestion of any part of the venous sys- 
tem is always concerned with a disordered action of the 
heart ; and sometimes, that disordered action originates in 
the heart itself, and at other times it is the effect of some 
disturbance in another organ. We shall not pause for the 
present to inquire, how the heart has derived its motion, 
but that motion cannot be directly or indirectly disordered 
to any extent without a shock to the system ; for when it is 
directly disordered, the circulation labours at its very 
source, and when it is indirectly disordered, the circulation 
is obstructed or disturbed in some of the main or minor 
streams. When the right side of the heart is preternatur- 
ally loaded with blood, the face and whole surface are gen- 
erally pale, and the pulse is feeble, and mostly irregular ; 
while the respiration is anxious and variable, and an op- 
pressive weight is felt in the vicinity of the pericardium. 
An intermittent pulse most frequently depends upon some 
obstruction in the course of the venous circulation by which 
the right side of the heart is not duly supplied ; and this 
obstruction is very often seated in the liver, and is denoted 
by depression of spirits, paleness of the skin, unnatural col- 
our of the feces, and more or less head-ache. But violent 
head-aches, and sometimes even venous apoplexies, are the 
result of an over-accumulation of blood about the right au- 
ricle and ventricle ; for in that case the venous blood is re- 
tarded in its return from the brain, and thus, though the 
cause may be in the heart, the effect falls on the cerebrum 
or cerebellum. Wherever I have made morbid examina- 
tions in those cases which bore the character of congestive 
disease, I have found the right side of the heart preternat- 
urally distended with very dark blood; and in reflecting 
upon their previous history, I cannot but be led to con- 



20 CHRONIC DISEASES, 

elude, that the function of the right ventricle was closely 
concerned in their pathology. If from any cause too much 
blood be returned to the right ventricle, say from the blood 
retiring from the superficial into the deeper seated veins, 
the whole venous circulation must by consequence become 
disordered; but those organs where the flow of venous 
blood is naturally the slowest, will be, most likely, the main 
seats of the local disorder ; and hence perhaps it is, that 
we so often find the brain and liver so congested with blood 
which is darker than usual. But in some instances no 
doubt a preternatural accumulation of blood takes place 
about the heart from a mere loss or diminution of muscular 
power in the right ventricle ; and this is perhaps the case 
in overwhelming shocks from fear, or accidents, in exces- 
sive and sudden abstractions of the animal heat, and also 
in the slow and insidious operation of those debilitating 
causes which break up the general strength. There is 
perhaps hardly a chronic or an acute disease in which the 
functions of the heart do not less or more participate ; and 
in fact the disturbed action of this organ, influencing topi- 
cal predispositions, is the source from which numerous 
complaints may be said to proceed. 

Whenever venous congestion exists as the cause of chro- 
nic disease, in the end it mostly occasions an increased ac- 
tion of the heart and arteries ; but this increased action is 
frequently imperfect and irregular for a considerable peri- 
od, so that there is fever at one time, and collapse at anoth- 
er, and between these two states the health is suspended. 
In fact, whenever the increased action of the heart and ar- 
teries is permanently established, then the venous conges- 
tion may be said to terminate in a new disease ; since an 
increased action of the heart and arteries is one of the nat- 
ural cures of venous congestion, and an augmentation of the 
secretions is the other. If we trace back the history of 
many of those cases of slow fever which we witnessed, 
whether in combination with organic disease or not, we 
shall frequently find, that the symptoms at the onset and 
part of the progress were those of venous congestion ; and 
again, in those cases where the symptoms of congestion 
have not been followed by fever, we shall invariably find, 
that some of the secretions had been augmented, and that 



AND SULPHUREOUS WATERS. 21 

thereby more or less temporary relief had at different pe- 
riods been obtained. 

One of the common modes in which chronic congestions 
of the veins are spontaneously lessened, is by a copious se- 
cretion of urine or perspiration; and I believe, that the 
skin, kidneys, and lungs, are the principal organs of de- 
fence against vascular fulness of all kinds. In a state of 
civilized society, we often eat and drink a great deal more 
than is requisite for the supply of our natural wants ; and 
how is the surplus managed that it may not dangerously 
distend or burst the channels qf the circulating fluid ? Where 
the blood-vessels are preternaturally filled, a secretion of 
urine takes place, or if that should fail, the perspiration be- 
comes abundant as a substitute ; but if both the kidneys 
and the skin should not perform their guardianship well, 
the lungs are thrown into an augmented motion, and their 
exhalation is also proportionably augmented. Doubtless 
the intestines sometimes assist in these offices of preserva- 
tion by an accumulation of part of the ingesta, and by an 
increased secretion from their villous coat ; but the skin, 
kidneys, and lungs are the principal organs by which we 
are secured against vascular fulness, though physiologists, so 
far as I know, have overlooked this important part of their 
functions. In cold, variable climates, few persons could 
exist long, if the lungs and kidneys did not secrete very 
copiously, when the blood recoils towards the central parts, 
from an abstraction of caloric on the surface ; and on the 
other hand, in hot countries, where so much fluid is drunk, 
and where the heat expands the blood, the danger would 
be equally great, if the skin and lungs did not exhale free- 
ly, since the secretion of the kidneys is then diminished. 
Even in this country we secrete more urine in winter, and 
more perspiration in summer : and both these changes 
tend to preserve us against plethora of the vital organs. It 
is notorious, that in what are termed nervous people, the 
urine is often plentifully secreted during their indisposi- 
tions ; and this circumstance has saved thousands from pal- 
sy or apoplexy, however trifling it may have hitherto been 
considered. A real suppression of urine is always danger- 
ous, and sometimes precedes great oppression of the brain ; 
and marks of vascular fulness invariably attend a diminish- 
ed secretion of the kidneys, unless the lun^s, the skin, or 



22 CHRONIC DISEASES, 

the villous coat of the intestines, should supply the deii- 
cient secretion by an increase of their own. Since the 
first edition of this work was published, I saw a case in 
which no urine entered the bladder for upwards of twenty 
hours, on account of a calculus which was sticking in each 
ureter. At first, the patient complained of considerable 
uneasiness in the head, in which there appeared to be a 
preternatural degree of vascular fulness ; but a copious per- 
spiration came on which gave very great relief, and which 
continued until the calculi passed into the bladder. They 
were both afterwards expelled ; but there can be little 
doubt, that the copious perspiration saved the patient from 
some cerebral attack. In most febrile disorders, the se- 
cretion of the kidneys and skin is diminished, while that of 
the lungs is increased : this diminished secretion in the for- 
mer organs affords a strong argument in favour of deple- 
tion, and whenever it is observed in chronic diseases of ve- 
nous congestion, additional care is required ; for there is 
then generally a danger of dropsical effusions from the ful- 
ness of the veins. If it were not deviating too far from the 
present subject of discussion, I could show that dropsy is a 
common consequence of venous congestion; and if to this 
we add local enlargements or local obstructions, and in- 
creased action of the heart and arteries, we furnish three 
great pathological principles, which embrace numerous 
dropsical diseases. Chronic congestions of the veins of 
the liver, if not relieved by an increased secretion of that 
or some other organ, has frequently a tendency to termi- 
nate in ascites ; and on examining the brains of some pa- 
tients, who had long been subject to symptoms of fulness in 
the cerebral veins, I have discovered a considerable quan- 
ty of fluid in the ventricles, which had probably been slow- 
ly effused. 

Sedentary are more liable than active people to the ve- 
nous modification of chronic disease, and old persons more 
than young ; but it may occur in any habit, or at any age, 
though both influence its character and cure. In sedentary 
people the circulation is apt to become sluggish for want 
of proper exercise ; and hence in them we often discern 
the clearest marks of venous congestion, without any proofs 
of arterial excitement. Again, in advanced life, the circu- 
lation undergoes a gradual, though remarkable change : the 






AND SULPHUREOUS WATERS. 23 

blood to a certain extent leaves the arteries, and accumu- 
lates in the veins, of which we have ocular demonstration ; 
and as there is an internal as well as external plethora of 
the veins, they are more subject to all the affections of ve- 
nous congestion than the young, in whom a brisk arterial 
circulation exists. Our cold and variable climate is pecul- 
iarly favourable to the production of congestive diseases, 
for often when the heat is abstracted largely from the sur- 
face, an internal accumulation of blood follows: and if this 
happen in an old or a delicate habit, it oppresses some vi- 
tal organ, and the arterial action remains subdued ; but if 
it should occur where there is much innate energy, an ex- 
citement is produced, which may be either of an acute or 
of a chronic character . 

It is not, however, our cold and variable climate alone 
which produces congestive diseases, for they may often be 
traced to the want of ventilation and cleanliness ; and 
hence their frequent occurrence among the poor, who re- 
side in crowded alleys and courts, where there is a deficien- 
cy both of fresh air and water. In visiting some of these 
places in the metropolis, I have been particularly struck 
with the squalid appearance of many of the inhabitants ; 
and could not but observe with regret, that the children 
were mostly strumous or rickety, apparently more from a 
defect of air and cleanliness, than of proper food. If some 
individuals of practical minds and of personal consequence 
would introduce some better mode of ventilating and warm- 
ing houses, their labours would be productive of great ad- 
vantage, but especially to the poor, whose abodes are the 
sources of contagious as well as chronic distempers in 
po'pulous towns ; for the confined situations, the small fires, 
narrow windows, and low doors, are all obstructions to free 
ventilation; and, on account of the inadequate supply or 
use of water, the stagnant atmosphere is loaded with putrid 
effluvia. Indeed the present method of w r arming and ven- 
tilating our houses is, at best, extremely defective ; the 
temperature being by no means uniform, and the ventila- 
tion chiefly from the windows elevated above the floors. 
The principle of ventilation should be to have an indepen- 
dent and a constant supply of fresh air from without, which, 
in our worst seasons, should be made of an equable and 
agreeable temperature by some apparatus for warming the 



H CHRONIC DISEASES, 

air in the interior. By a system of this sort, the strength 
would be maintained by the unceasing freshness of our do- 
mestic atmosphere ; and not only would there be much less 
risk to the delicate within doors during bad weather, but 
they would be able to go comfortably warm into the cold 
air abroad, which is the best way of resisting its influence. 
As carburetted hydrogen gas can now be so easily extract- 
ed from coal, our houses might be ventilated, warmed, and 
lighted, by a modification of the same apparatus ; and as 
small coals, which are exceedingly cheap, would answer 
for the fires, an immense reduction of domestic expendi- 
ture would be the result, though the chief advantage would 
consist in improving the health of the poor. One of the 
great secrets for the preservation of health in large towns is 
to take plenty of exercise in the open air: this remark is 
peculiarly applicable to London, where most of the seden- 
tary are very sickly looking, and where most of those who 
are much in the air appear as healthy as in the country ; 
but this is especially the case with children, and therefore 
exercise abroad is a point to which parents should constant- 
ly attend in the metropolis. 

But, to proceed with the original topic, at every period 
of our existence, the veins will bear certain degrees of dis- 
tension without disordering the functions of any of the res- 
pective viscera ; but if this distension exceed a certain 
measure it becomes a disease, and of course the phenome- 
na of that disease are modified by its seat and degree, and 
by the state of the constitution in which it occurs. Indeed 
in the investigation of chronic congestions of the venous 
system, it is of great consequence not only to discover the 
organ chiefly oppressed, but also to ascertain the age, hab- 
its, and other peculiarities of the patient; for variation 
in the seat of the disease may require some variation in 
the application of remedies, though the general princi- 
ples of cure are chiefly to be modified by the consti- 
tutional circumstances above noticed, and by the stage of 
the disease. If, for example, chronic congestion of the 
veins exist in a person, whose general powers are only op- 
pressed, the debility is not real, but apparent, and the con- 
sideration of it must not be allowed to stand in the way 
of moderate depletion; but on the contrary, if chronic 
congestion of the veins exist in combination with the 



AND SULPHUREOUS WATERS. 25 

real debility attendant upon exhausted powers, then the 
congestion might be increased by depletion, and a fatal 
collapse would probably succeed. Again, if the chronic 
congestion of the veins has been of long continuance, 
its treatment requires considerably more nicety, than 
when it has only been of comparatively short duration : 
for when it has continued a long time, the debility may 
be real, and there may also be some co-existent derange- 
ment in the structure of the part affected. In the consid- 
eration of the cure of acute diseases, I have made various 
attempts to show how important it is to mark the line of 
separation between real and apparent debility; and it will 
be found equally important to attend to this in the treat- 
ment of chronic diseases, since what may be proper in a 
state of oppression, is exceedingly improper in a state of 
unquestionable weakness. , In most systematic works, how- 
ever, we have mere incidental symptoms enumerated as 
the chronic diseases themselves, without regard to the seat 
or nature of those diseases ; and it is not uncommon to find 
diffusible stimulants recommended, where evacuants alone 
are demanded, and vice versa, as might be instanced in ma- 
ny of those diseases which are comprehended under the 
class neuroses. When chronic venous congestion only 
masks the strength of the patient, by impeding the functions 
©f some vital or important organ, it is best removed by 
evacuations; but when it is combined with an actual want 
of tone in the heart and whole muscular fibre, diffusible 
stimulants are necessary, as shall afterwards be shown, -in 
an outline of the methods of treatment. 

It has already been remarked, that a deficiency of heat 
and of arterial action attends the first stages of chronic con- 
gestion in the veins wherever seated; and it may be here 
noticed, by way of contrast, that an excess of heat and of 
arterial action attends diseases of chronic excitement. But 
at the same time it must not be forgotten, that diseases of 
chronic excitement may arise out of diseases of chronic 
congestion in the veins, just as the hot stage may arise out 
of the cold stage of an acute fever : for in both cases the ve- 
nous congestion may become an irritant to the arteries, by 
the stimulus of the distension applied to the right side of the 
heart, from the return and accumulation of the venous blood 
there, and in both cases the arterial excitement may be the 

D 



26 CHRONIC DISEASES, 

natural cure of the venous congestion. It is indeed upon this 
principle that we may trace the origin of several of those 
chronic excitements which are so common about the vital 
organs. For if we inquire into the primary symptoms we 
shall not unfrequently find, that they were those of venous 
congestion, produced by the operation of cold upon the 
skin, by the depressing passions, by sedentary occupations, by 
fatigue, or by some shock which retarded the arterial circu- 
lation, and made a recoil of blood towards the interior ; 
while the arterial excitement was but an effect of that 
venous congestion, an action established to restore more 
effectually the natural balance between the venous and 
arterial systems. The congestion of the veins, how- 
ever, often continues a long time before it produces ex- 
citement in chronic diseases, and may be so great as 
wholly to prevent it, as happens in acute diseases ; but in 
the latter the congestion is suddenly formed, whereas in 
the former it is commonly the accumulated result of days, 
of weeks, of months, or even of years. In chronic dis- 
eases, there is, on certain occasions, a sort of interchange 
between venous congestion and arterial excitement for some 
time, until the one or the other decidedly predominate, or 
until the system be restored to health. The venous con- 
gestion first produces arterial excitement, and the excite- 
ment in its turn ends in a loss of arterial tone, and thus 
alterations take place, until the equilibrium of the circu- 
lation be decidedly lost or restored. 

But chronic excitement of the heart and arteries more 
frequenly arises directly from an excess of stimulation, than 
indirectly from venous congestion. Many of the habits of 
civilized society at once tend to produce chronic diseases 
of the arterial system ; but among the most common caus- 
es of these diseases, may be enumerated the use of ardent 
spirits among the lower orders, and of wine and rich diets 
among the higher. Every time that ardent spirits are taken, 
we stimulate the heart and arteries preternaturally, and if 
this increased action be frequently repeated by the same or 
any similar excitant, chronic inflammation rarely fails to 
supervene at last ; and this inflammation for the most part 
falls on the brain, or its meninges, the liver, the pancreas, 
the^villous coat of the stomach, the peritoneum, or the kid- 
neys. Of the spiritous liquors which are daily drunk in 



AND SULPHUREOUS WATERS. 27 

such lamentable abundance, rum seems to be the least per- 
nicous; for those who confine themselves to it generally 
are less emaciated, and hold out longer than those who 
drink brandy or gin. Rum does not constipate the bowels 
so much as either of the others, and it contains some sac- 
charine matter, which probably sheathes the stomach in 
some degree, and acts as a laxative ; but the baneful in- 
fluence of all spirits is diminished by combining them with 
acids, and hence we find the drinkers of punch, upon the 
whole, suffer the least. As for brandy and gin, when taken 
raw, or diluted simply with water, they both tend to consti- 
pate the bowels, the first acting most powerfully on the liv- 
er, and the last on the kidneys : yet their operation, like 
every other diffusible stimulus, is not limited to any particu- 
lar part, but extends throughout the whole arterial system 
from the force communicated to the heart, whence it is 
transmitted to the arteries ; so that if any one organ hap- 
pens to be weaker than the rest, the principal disturbances 
will be occasioned in that organ, from the heart continuing 
to send thither greater quantities of blood than natural. 

It is a striking circumstance in our national character, 
that hardly any concerns of consequence can be transacted 
by any body of men, without what are called good eating 
and drinking; and this is more especially the case in com- 
mercial towns, where men gorge themselves with rich food 
and strong drinks, when called together by business. There 
are far more chronic diseases in commercial, than in coun- 
try towns, in proportion to the population of- each; and 
the principal cause of this is, the greater dissipation which 
prevails in the former, and which gives employment to 
crowds of medical men, half the number of whom would 
be unnecessary, if temperate habits could be established. 
Let any practitioner who resides in a large commercial 
town mark the diseases which fall most frequently under 
his observation, and he will find, that they are those which 
arise from dissipation of one sort or other ; and if he com- 
pare his experience with that of any medical friend in a 
country place, he will find, that such diseases are propor- 
tionably far less common in the practice of the latter. If 
mild ale, properly brewed from the malt and hops, could 
be introduced to the utter banishment of those poisons 
termed distilled spirits, what an immense change for the 



28 CHRONIC DISEASES, 

better would be effected in the health and happiness of the 
nation ; and as the use of these liquors has become so gene- 
ral and so destructive, the subject is surely deserving of 
the serious consideration of the legislature, both in a med- 
ical and moral point of view. It is remarkable, that if we 
taste twenty different ales, the flavour of hardly any two is 
at all alike, which shows that there are various methods of 
brewing even this our old national beverage ; and as it is 
now notorious, that there are druggists who travel for orders 
amongst the brewers, we have strong grounds for infer- 
ring, that the modern method of making ale is far less 
wholesome than the ancient. This subject, too, demands 
a strict inquiry, for the national health ought not to be 
bartered away to the selfishness of individuals. In a for- 
mer page, I have expressed my opinion as to the unwhole- 
some properties of porter ; for, according to my observation, 
it is not an unfrequent cause of palsies and apoplexies, as 
well as of chronic inflammations of the vital organs in 
general. Whether the bad effects of this liquor depend 
upon the concentrated spirit which it contains, or upon 
some narcotic which it has been supposed to contain, does 
not appear to be certainly known ; but as from repeated 
experiments I have found its operation almost precisely 
similar to that of opium, I cannot but entertain strong sus- 
picions, that some narcotic is actually infused, and could 
therefore wish, that some able chemist would undertake an 
extensive analysis of this drink, for the sake of the public. 
By our enemies it has almost become a reproach, that we 
are a money-making people ; and as the love of money is 
one of the most degrading passions, we ought to guard 
against its influence in the great concerns of health and 
morality. So far as I have been able to ascertain, it is one of 
the most remarkable peculiarities in the habits of the lower 
and middle ranks of society in London, that they take 
porter much more as a common drink than in any other 
place of the kingdom. This habit is surely most perni- 
cious, since it must necessarily create a gradual and increas- 
ing desire for a stimulant, the effects of which are powerful 
upon the nervous and vascular systems. When Dr. Frank- 
lin, the American, was a printer in London, he was the 
strongest man among many in a large oflice, though he 
drank nothing but water, while most of the others indulged 



AND SULPHUREOUS WATERS. 29 

in diffusible stimulants, from an idea that they supported 
their strength; and I am firmly persuaded, that the inhab- 
itants of large towns would be much more healthy than 
they generally are, if they lived upon a nutritious diet, 
and only drank water, or some very mild malt liquor ; for 
the wear and tear of mind and body, from the greater de- 
mand for the exertions of both in large towns, is quite suffi- 
cient, without- superadding the irritation and exhaustion 
which must result from the daily use of stimulating drinks. 
Many persons in the higher circles are troubled with 
what are popularly denominated stomach complaints ; and 
it is well known how untractable they are under the tonic 
plans of treatment, which are usually pursued. But the 
truth is, that these diseases generally are combined with 
chronic inflammation, or with increased actions of a chro- 
nic nature ; and therefore it is irrational to expect, that 
they can be removed by means directly tending to aggra- 
vate the very cause from which they proceed. The man- 
ner in which persons of the higher ranks take exercise, the 
stimulant drinks and diets which they use, the unseasonable 
hours which they keep, all tend to disorder the digestive 
and hepatic functions, and, through them, to affect the 
brain and its membranes ; and therefore the seats of those 
disorders, which are so commonly supposed to be of the 
nervous class, are to be found in the head, in the stomach, in 
the liver, or in some other important organ. Carriages 
are extremely convenient, and even necessary, for those 
who have certain duties to perform which require dispatch, 
and they are also excellent protections against the influ- 
ence of our bad climate at certain seasons of the year ; but 
to make them, as is generally done, a sort of daily vehicle 
for exercise, is preposterously absurd, as if nature had al- 
most made our moving powers in vain, As walking is the 
natural exercise, so it is unquestionably the best for those 
desirous to maintain strength and health at the same time; 
and carriages should be appropriated to those invalids who 
stand in need of fresh air without fatigue, and to those in- 
dividuals whose time is valuable, or whose frames are too 
feeble always to stand the shocks of our coldest seasons. 
Jt would be a great improvement in our domestic habits, 
if the second courses at dinner were abolished, among the 
higher ranks of people, as they generally induce them to 



30 CHRONIC DISEASES, 

eat more in quantity and in quality than is requisite or sal- 
utary. In fact, in the first course of dishes there is far too 
much variety ; and it is unnatural to expect, that the di- 
gestive powers can accommodate themselves to such a mix- 
ed farrago of materials. If we look throughout nature, we 
shall find, that all living creatures, excepting man, exist on 
a very simple fare ; and the result is, that while his life ter- 
minates at all ages, theirs is usually lengthened out to the 
latest date of their respective genus, when left in a state of 
nature. In examining the bodies of those animals killed 
in the chase, which have now and then fallen in my way, I 
have hardly ever found any chronic disorganization about 
their vital organs ; but in examining some of those who 
had been domesticated, and consequently had partaken of 
our complicated and unnatural diets, organic disease was 
found in almost all of them. Mr. Forster, too, who has 
written an ingenious book on Atmospheric Phaenomena, 
observed similar facts ; and it cannot be doubted, that de- 
viations from simple habits produce the same effects in man 
as in the lower animals. It is an old proverb, and perhaps 
a true one, that a skilful cook is more to be feared in the 
time of health, than an ignorant physician in the time of 
sickness. The sum of disease and suffering would be great- 
ly lessened, if we would abandon our delicacies, and be 
content to live upon a very plain diet. 

But it is not the circumstance of complicated meals alone 
that requires amendment, since the pernicious custom of 
drinking wine should be almost wholly given up, unless 
long habit may have rendered it to a certain extent a ne- 
cessary evil. The truth is, that in habitual tipplers we 
can seldom make sudden and great changes in regard to 
diffusible stimulants, without the risk of inducing some 
dangerous diseases, but particularly those of a dropsical na- 
ture. For when the artificial stimulus is at once with- 
drawn, the heart falls into a sort of collapse, the pulse 
becomes weak, the blood accumulates in the veins, and na- 
ture relieves the superabundant fulness, by an effusion of 
serum from the extreme vessels. But where tippling has 
not been long habitual, it may safely be abandoned at once 
in young persons, by the substitution of ale for wine or spir- 
its ; but in people advanced in life, we must proceed more 
cautiously, and gradually lessen their ordinary stimulus. 



AND SULPHUREOUS WATERS. 31 

otherwise they will be almost certain to become dropsical. 
from the cause above mentioned. Many men would be 
shocked if one were to tell them that they are drunkards, 
and yet to a certain extent they really are. so ; for though 
they themselves may account five or six glasses of wine in 
the day perfect sobriety, yet it is far too much, and can- 
not fail to do mischief in the end. In fact, it is habit alone, 
that renders wine at all necessary, and water or mild ale 
should be the universal beverage; and the latter is cer- 
tainly requisite in some weak constitutions, but particular- 
ly in those of the strumous temperament, who should never 
live too low. We have already deviated so far from the 
simplicity of our natural instincts, that we could not return 
to them with safety ; for habit is a sort of second nature, to 
which we are compelled in some measure to conform, from 
the changes which it has wrought in our constitutions. — 
Some few men might be found who daily drink wine or 
spirits in considerable quantities, without apparent preju- 
dice to the health ; but these are individuals whose Her- 
culean strength would almost resist any shock. It is self- 
evident, that wine and spirits destroy the health and short- 
en the life of most of those addicted to their intemperate 
use. When the appetite is impaired by wine and spirits, 
they soon undermine the fabric of some vital part in the 
animal machine ; and those drunkards in general hold out 
the longest, whose appetites remain unimpaired, provided 
they keep clear of apoplexy or similar affections. Excess 
of eating produces nearly the same effects as excess of 
drinking, in preternaturally stimulating the heart and arte- 
ries, and in leading to diseases of chronic inflammation: 
Celsus has correctly observed, that the first is for the most 
part more immediately dangerous than the la>t. The rea- 
son of this is, that the liquids sooner pass off by the secre- 
tions, and thus the vessels are relieved of fulness. Solids 
are long retained in the stomach, and when largely taken. 
they disorder the circulation, not only by their stimulus, bin 
by their pressure against the diaphragm and descending 
aorta, while the superabundant fluids, finally formed from 
them, are more slowly eliminated by secretion. Many bi 
the habits of civilized society not only stimulate the heart 
preternaturally, but also tend to produce and maintain a 



32 CHRONIC DISEASES, 

state of plethora, by the operation of one or both of which 
a train of chronic excitive diseases is occasioned. 

The drinking of wi»e at dinner in the higher circles is a 
fashion that might be well dispensed with : indeed it is a 
sort of initiation into tippling, not only among men, but also 
females ; for if the party be large, it is difficult to avoid 
taking two or three glasses at the least. Upon the suscep- 
tible nerves of females, two or three glasses of wine have 
considerable influence. To this trifling quantity taken dai- 
ly I have sometimes been able to trace the rise of those 
chronic inflammations of the viscera, which are so often 
confounded under the terms bilious, dyspeptic, nervous, 
and the like; and as most men among the upper ranks 
take considerably more wine than this every day, it is not 
surprising, that they should be the frequent subjects of sim- 
ilar complaints, particularly if we take into the account 
their stimulating diet, and late hours. It is said that the 
private use of opium is fast increasing amongst the upper 
classes, as a temporary stimulant against those feelings of 
exhaustion which their artificial modes of life naturally 
produce ; but if any thing be calculated to render a human 
being miserably dependant, it is the habitual use of opium ; 
for when its excitive operation ceases, an anxiety and irri- 
tation succeed which are almost insufferable, until the 
wonted stimulus be again supplied by this powerful drug. 
But whatever may be the case among the higher, it cannot 
be disputed, that opium is far more extensively used among 
the lower and middle orders than formerly ; and indeed 
few people now hesitate to prescribe it on many occasions, 
without ever consulting their medical attendants, as if it 
were a simple and innoxious medicine. In fact it is even too 
often and indiscriminately given by professional men them- 
selves, many of whom, from the long habit of prescription, 
forget that sleep cannot be procured by it, without the 
brain being gorged with blood. It may be safely asserted, 
that in every person under the full soporific influence of opi- 
um, as under that of intoxication, the vessels of the brain are 
in a state approaching towards apoplexy. Some most dis- 
tinct cases of palsy and of apoplexy have fallen under my ob- 
servation, whsch arose from too large, or too often repeated 
doses of opium ; and I would particularly caution the facul- 
ty in general, against the too common practice of giving 



AND SULPHUREOUS WATERS, as 

anodyne draughts night after night, because their effects 
may at last be extremely prejudicial. The increase of pal- 
sies, of apoplexies, and of many similar affections of the 
cerebrum, is in my opinion closely connected with the in- 
creased consumption of opium, and perhaps with the abuse 
of mercury, ft is not the brain alone which suffers from 
the injudicious employment of opium, for it excites the 
whole vascular system under the ordinary states of the con- 
stitution. Some opportunities have occurred to me of ex- 
amining the bodies of patients who had been habitual takers 
of opium : and in all of them there was extensive organic 
disease, and the vestiges of chronic inflammation were most 
apparent in the brain and liver.* But if opium be thus 
hazardous when exhibited under the ordinary conditions 
of the body, there are extraordinary ones in which it is 
highly beneficial ; and among these may be enumerated 
violent pain, real exhaustions of the heart, and irritations 
of the nervous system. In fact there are many cases of 
inflammation, but particularly of the stomach and bowels> 
in which opium is far too little exhibited by the faculty, 
under an apprehension that it constipates the intestines, 
or merely masks the symptoms. Yet though opium un- 
questionably constipates the bowels in health, this is not 
the case in inflammation of the stomach and bowels, as I 
have repeatedly witnessed ; for under such a state, by al- 
laying pain and irritation, it often assists the operation of 
purgatives, and in conjunction with them and with blood- 
letting, is one of the most powerful measures which we can 
employ, however systematics may protest against it in such 
examples. It is, therefore, only against the administration 
of this medicine in the more common conditions of the 
habit, that we ought to be so much upon our guard ; and 
from want of due attention to this particular, it is now be- 
coming a poison in soeiety, profusely and indiscriminately 
given. 

* It would be extremely interesting and useful to be informed, more ac- 
curately than we hitherto have been, of' the diseases to which the opium 
takers iu Turkey art so liable. They seem to be chiefly affections of the 
brain, as they are attended with derangements in the moving powers. It 
is to be hoped, that some intelligent traveller will hereafter attend particu- 
larly to the subject, and give us a correct history of the effects of this nar- 
cotic in Turkey. 

E 



34 CHRONIC DISEASES, 

Next to the abuse of opium in this country, I would rank 
that of calomel, a medicine far too much given in chronic, 
and far too little in acute diseases ; for while, when adminis- 
tered with due discrimination, I have never known it pre- 
judicial in acute diseases, many instances have been pre- 
sented to me where it seemed to have broken up the health 
in chronic diseases. In this and in a preceding work, I 
have spoken confidently of the united or separate efficacy 
of calomel and opium, in acute diseases of arterial excite- 
ment or venous congestion, and could speak with almost 
equal confidence of their utility in some chronic ones ; but 
the operation of all medicines is powerfully modified by 
the condition of the system at the time of their administra- 
tion, and always to give calomel and opium in the same 
way is to convert an antidote into a bane. The irregular 
and empirical manner in which calomel is often prescribed 
in chronic diseases, without due regard to the nature of the 
symptoms, or to the powers of the patient, not unfrequently 
paves the way to chronic affections of the brain or of other 
vital parts ; and on a strict examination we shall sometimes 
find, that paralytic or dropsical persons previously to the 
attack, had taken mercury long or largely when it had not 
been required, and without most or any of those precau- 
tions which were necesssary at the time. It is a remarkable 
fact, according to my observations, that most men who have 
broken up their strength by unnecessary or irregular cours- 
es of mercury, have a scrofulous offspring when they marry ; 
and 1 believe an extensive inquiry into the general state of 
health, would bear me out in the assertion, that the alarm- 
ing progress of scrofula in this country, is intimately con- 
nected with the veneral disease, and with the abuse of 
mercury. But it is time to resume the continuation of the 
original topic. 

There is one point so closely concerned with the pro- 
duction of chronic diseases of excitement, that I cannot 
refrain from distinctly adverting to it, and the more espe- 
cially as it relates to a part of medical practice which 
stands in need of immediate reformation. When patients 
are convalescent from acute diseases of venous congestion, 
or of arterial excitement, it is an established rule among 
many practitioners, to allow them a generous diet ; and 
some go even further than this, as they prescribe wine and 



AND SULPHUREOUS WATERS. 35 

what are called tonics, with the hope of more rapidly re- 
cruiting the strength. It is not intended in these pages to 
insinuate any thing^ against others, for this was the practice 
which I once pursued myself; and it was from observing 
its bad effects in many instances, that I was led, generally^ 
to abandon it, and to substitute one more consonant and 
salutary to the system. When any acute disease has sub- 
sided, no matter where seated, it commonly leaves a ten- 
derness or weakness in the organ which had sustained the 
main attack ; and it is highly probable, that the capillaries 
of that organ had undergone a change during the disease, 
and that some of them may have been closed or obstructed 
in such a manner as to modify the future circulation of the 
part. 'But be this as it may, it cannot be questioned, that 
a peculiar delicacy remains in a part which had been acutely 
inflamed or congested ; so that the original disease may 
be renewed by the application of certain powers. This 
delicacy sometimes remains a long time, inasmuch as those 
who have once had attacks of cynanche, erysipelas, rheu- 
matism, and the like, are very subject to them again. Now 
when we give a nourishing diet, with wine and tonics during 
convalescence, are we not in danger of once more exciting 
or disturbing the circulation of the organ which had been 
so recently the seat of severe disease ? If we examine 
into the human body, we shall find, that the heart is the 
seat of government, the centre of motion ; and if the cir- 
culation of any one part be already in some degree less 
healthy than the rest, increasing the action of the heart 
must propel more blood in that direction, and the blood 
thus propelled may re-produce disease. This is not theo- 
retical speculation, fori have known many cases of chro- 
nic inflammation arise after acute ones from following the 
stimulant plan during the appearances of convalescence : 
and since I have adopted a more cautious, and in fact a 
different system, such occurrences have been comparative- 
ly rare in my practice. After all great disease the consti- 
tution falls into a state of collapse, from which it is gradu- 
ally recruited by the innate powers, provided proper 
support be given ; but if on the one hand we give too 
spare a diet, great bodily and mental irritation succeeds; 
and if on the other we give too full a diet, the heart and 
arterial circle are stimulated to excess, and an acute, sub- 






36 CHRONIC DISEASES, 

acute, Or chronic inflammation may supervene. It is never 
safe to attempt to rouse the constitution at once from col- 
lapse into strength. In reality it cannot be done, for when 
the powers are over-exhausted, their vigour can only be 
gradually restored. On all occacions, therefore, of con- 
valescence from fevers, it is better to allow the system to 
renovate by light cooling support, than to stimulate it by 
strong food, wine, and tonics ; and though there be many 
cases which require a deviation from this plan, on account 
of the extreme exhaustion of the patient, yet they will be 
found few in comparison to those which require an opposite 
plan. From long and unbiassed observation, 1 am fully 
convinced, that most of the medicines called tonics, are 
either useless or pernicious ; and if these were erased from 
the pharmacopoeias, it would be a real benefit to the pro- 
fession and mankind, for they only serve to mislead the 
former, and to tantalize or injure the latter. Tonic med- 
icines generally oppress the digestive functions, or operate 
as direct stimulants, and in either case they are improper 
in convalescence ; for by the first they may destroy the 
natural appetite, and by the last they may lead to chronic 
inflammations. So far from such drugs being appropriate 
to a stage of convalescence from acute disease, mild laxa- 
tives are most frequently requisite to preserve a right 
balance between the ingesta and the egesta : and the prac- 
titioner who substitutes the former will find that his patients 
will pass better through convalescence, and be afterwards 
far less subject to consecutive attacks of inflammation. 
During convalescence from acute diseases, the two circum- 
stances most to be avoided are exposure to cold, and too 
full a diet ; for by far the greatest part of relapses may 
clearly be referred either to the surface being chilled, or 
to an over-excitement by the formation of too much blood 
from excess of nutriment. In relapses from both these 
causes the use of the lancet will generally be necessary, 
particularly when they proceed from the plethora of too 
generous food 5 but if the patient be put into a tepid bath 
on the first occurrence of the chill, the accession of second- 
ary fever will often be prevented, especially if a brisk pur- 
gative be afterwards given. But if these secondary fevers 
be neglected in the onset, they will most frequently have 
an unfavourable issue, from the supervention of some acute 



AND SULPHUREOUS WATERS. 37 

inflammation of the viscera ; or even if this at last should 
be successfully resisted, it will often leave a strong tendency 
to chronic inflammation of the part, which may be easily 
excited, from the stimulating drinks and diets to which 
most persons are now daily accustomed. 

The general symptoms in diseases of chronic inflamma- 
tion are increased heat, and increased action of the heart 
and arteries ; and the particular symptoms are topical un- 
easiness and disorder in the functions of the organs affect- 
ed. The increased heat and action, however, are fre- 
quently so slight, that they might escape the notice of a 
cursory observer for sometime after their commencement; 
and the same may be said of the topical uneasiness and 
disordered functions, as they, too, are often most obscurely 
denoted at first. In all suspicious cases, therefore, of a 
chronic nature, the practitioner must endeavour to ascer- 
tain, by minute investigation, the states of the vital organs 
within ; and if there should not be evidences of chronic con- 
gestion in the veins, let him inquire whether there be 
chronic excitement of the arteries. The brain or its me- 
ninges, the stomach, the peritoneum, the kidneys, the ute- 
rus, and the liver, are more frequently the seats of chronic 
inflammation than other parts ; and on this account some 
concise allusions may be made to them, by way of elucida- 
ting the general character of this class of affections. 

When chronic inflammation occurs in the brain or its 
meninges, there is frequently some degree of soreness or 
tenderness on pressure in the integuments of the head ; but 
this symptom is sometimes absent long after the com- 
mencement of the inflammation, though it is now and then 
present from the first, and almost always in its advanced 
stages. The eyes often feel as if small particles of sund 
were in them ; or they are liable to be inflamed from slight 
causes ; and this indeed is occasionally so much the case, 
that patients themselves imagine their disease to be entire- 
ly in the eyes, when it is purely secondary of the cerebral 
inflammation. The complaint called gutia Serena, or 
amaurosis, is frequently the product of chronic inflamma- 
tion in the brain, and not an idiopathic disease of the eyes, as 
manybave supposed. In chronic inflammation of the brain, 
however, the eyes are sometimes little or not at all affect- 
ed ; but then the hearing, the smell, or some other of the 



38 CHRONIC DISEASES, 

external senses, for the most part suffers in a degree, and 
the periods of sleep and of watching are less regular than 
in health. Pain, fulness, weight, tightness, throbbing, gid- 
diness, or some feeling, of uneasiness, invariably exists with- 
in the head : and the voluntary and mental powers are more 
or less implicated during the progress of the disease, the 
indications of which are various. The affection of the vol- 
untary powers may be marked by weakness or pain in the 
extremities, by defect or loss of power in some of the 
muscles, by a sense of numbness, or by an alteration in 
the gait, or in the mode of speaking; while the affection of 
the mental powers may be marked by a variation in the ex- 
pression of the countenance, by an unusual lassitude or 
restlessness of mind, by a defect of memory, by a change 
of the temper, or by unexpected deviations from accustom- 
ed habits or pursuits. The face is pale in some cases, and 
flushed in others, the pulse mostly fuller than in health, but 
though it be sometimes smaller, it is alwaj 7 s more frequent 
and generally harder ; and the temporal arteries usually 
beat more forcibly than natural, and the heat of the hairy 
scalp is somewhat above the ordinary standard. The stom- 
ach sympathizes more or less, though when the disease is 
principally confined to the head, the dyspeptic symptoms 
want that permanency of character which attends a fixed 
disease of the stomach •, but at the same time it is not un- 
common for inflammation of the brain to be combined with 
increased actions both in the stomach and the liver, and 
the cerebral may precede the abdominal symptoms, or the 
converse may be the case. There seems to me at present 
too great a tendency amongst medical writers, to ascribe 
the origin of affections of the brain to disorders of the di- 
gestive organs ; for though it cannot be denied, that the 
brain is often sympathetically disturbed from morbid states 
of the digestive organs, yet it as often happens, that the 
disorder of the digestive organs is secondary of that of the 
brain. But I suspect that the mistake has arisen from want 
of due attention to the early symptoms of cerebral disease, 
which are often extremely obscure for a considerable pe- 
riod ; and yet all the time they may be operating on the 
digestive functions, until the disturbances in the latter be- 
come conspicuous links in the morbid chain. Chronic in- 
flammation of the brain may be the precursor of apoplexy. 



AND SULPHUREOUS WATERS- 39 

of palsy, of epilepsy, of acute phrenitis, and of mania, all 
of which are extremely unmanageable when they thus se- 
condarily supervene : and it is truly surprising to vvliac a 
variety of symptoms an apparently similar affection of the 
brain will lead indifferent individuals; so that in one it 
shall assume the character of nervous head-aches, in anoth- 
er that of chor ia, in a third that of the falling sickness, and 
so on, from some idiosyncrasy of constitution which we 
cannot explain. This variation in the symptoms of cere^ 
bral disease, from apparently a similar cause, is often strik- 
ingly displayed in those families where madness is known 
to be hereditary. In many instances, chronic inflammation 
of the brain, or of its membranes, proceeds months or even 
years before it produces any dangerous or mortal result; 
and during the greater part of its progress it may be mis- 
taken for some disease of debility, or for some of those 
anomalous affections which have usually been supposed to 
originate from indigestion, or from an irritable state of the 
nervous system. 

When the stomach is chronically inflamed, pain, soreness, 
or uneasiness of some sort will be experienced on forcible 
pressure over the epigasrtic region ; except when the in- 
flammation is solely confined to the villous coat, and then 
it will mostly be marked rather by a sense of heat, a desire 
for cold drinks, and a gnawing feeling, than by positive 
pain, soreness, or tenderness. Flatulence, foul tongue, 
small pulse, and thirst, usually attend every form of chronic 
inflammation of the stomach ; and if there should not be 
nausea or retching, the appetite is either prostrate or ex- 
tremely capricious. In marking certain cases of chronic 
inflammation of the stomach, it has struck me, that the in- 
creased action may be protracted, lessened, or perhaps 
even cured, by a copious secretion from the lining of that 
organ ; for 1 have known some patients complain of great 
increase of uneasiness, and soon afterwards they vomited a 
quantity of glary mucus, after which 'they obtained tempo- 
rary or permanent relief. Wlien we consider how the 
stomach is abused, it is surprising that it should not be more 
frequently inflamed; and it is not improbable, that attacks 
of inflammation are often prevented by an increased se- 
cretion, which follows the use of unnatural stimulants. 
The irritation of the tenia occasionally produces symptom? 



40 CHRONIC DISEASES, 

somewhat similar to those attendant upon chronic inflam- 
mation of the stomach; and in" most obscure affections of 
the belly, the existence or non-existence of this worm 
should be ascertained, if possible, by a daily inspection of 
the stools. Chronic inflammation of the peritoneum is at- 
tended with some of the symptoms of a like disease of the 
stomach ; but in the former the tenderness is more diffu- 
sed, the whole abdomen is fuller and rounder, and the res- 
piration is more disturbed on motion. In both a slow and 
irregular fever accompanies the inflammation, with lass of 
flesh and strength, pale face, and quickened pulse ; and in 
both when they take place in females, it is common to com- 
plain, that the stays cannot be braced tight without uneasi- 
ness, and the abdomen often becomes so much swollen 
towards night, as to require the laces to be slackened or 
unbound. Chronic inflammation of the liver may be easily 
mistaken for a stomach disorder, as it is always accompa- 
nied with signs of indigestion, often with distension, pain, 
o*r soreness in the epigastrium, and sometimes with attacks 
of spasm referred to that region* The spirits are in gene- 
ral peculiarly depressed in chronic inflammations of the 
liver, and the complexion becomes pale, sallow, or yellow- 
ish, but so far as I have observed, more frequently of the 
two first mentioned^shades than of the last. The urine has 
sometimes a tinge of bile, and sometime not, though it is 
generally deeper in colour, and less in quantity than is usual. 
The feces become invariably unnatural, and in some cases 
are light, in others dark ; and the bowels are commonly 
bound, but occasionally in a contrary state. An uneasy 
feeling of weight is not uncommon in the centre of the 
sternum, and more or less cough generally attends; and 
the parent is shorter of breath than before, and is now and 
then liable to an oppression about the chest, as if he were 
confined in a close atmosphere. Some uneasiness is for 
the most part felt under the false ribs of the right side on 
forcible pressure, which is apt to occasion some tendency 
to.sickness ii» certain instances ; and a degree of pain or of 
dragging weight is often experienced on turning over upon 
the left s de, or the patient can only lie comfortably upon 
his right side or his back. Yet in a few cases of chronic 
inflarnrnat on of the liver, I have known no uneasiness what- 
ever induced by lying on the left side ; though in them the 



AND SULPHUREOUS WATERS. 41 

patients could generally go to sleep best on the back, with 
the head and shoulders a little raised. In chronic affections 
of the liver, palpitation of the heart is often excited by ly- 
ing upon the left side. Pain is as often absent as present 
at the top. of the right shoulder; and in some cases it is felt 
in the left shoulder, or between the scapulae. More or less 
head-ache or giddiness generally exists, and there is also 
more irritability of mind and of body than in health. The 
tongue is usually furred, the appetite impaired, and an ir- 
regular fever arises during the advancement of the disease, 
mostly attended with morning remissions and evening exa- 
cerbations ; but most frequently there are symptoms of in- 
disposition, and a loss of colour, flesh, and strength, for 
some time before the constitution is excited into evident 
fever. The ultimate effect of any chronic inflammation in 
the abdomen is to derange the natural structure ; but when 
the peritoneum or liver is affected, dropsy of the belly of- 
ten likewise supervenes. 

In certain instances, the brain or its membranes are 
chronically inflamed at the same time with some of the ab- 
dominal viscera, so that it is not uncommon to hear pa* 
tients complain of the head and belly together, and in such 
examples the stomach or liver will generally be in fault. 
By accurately tracing the symptoms as they rise and ad- 
vance, most internal inflammations of a chronic nature may 
be detected ; and though many of the symptoms may fluc- 
tuate from the consent between one part a id another, yet 
those arising from the organ really affected will hold a 
pretty permanent course. In estimating the character and 
seat of chronic diseases in general of the vital parts, it is of 
great consequence to ascertain what symptoms are station- 
ary, and what temporary : for the temporary symptoms 
only mark a tendency to disordered action, from some sym- 
pathetic or incidental cause ; whereas tlie stationary symp- 
toms indicate positive and progressive disease, and on this 
account ought to claim the special care of tlie medical at- 
tendant. Some of those people denominated nervous are 
in a peculiar state for months or even years, from the suc- 
cessive disorders of function in one organ or other at va- 
rious times ; so that they may be constantly complaining, 
and yet their complaints may have neither a permanent 
seat nor character. Such patients are generally wor&t in 

F 



42 CHRONIC DISEASES, 

the mornings, improve as the day advances, and commonly 
feel best towards night : but this is rarely the case in fixed 
diseases of the internal organs, for indeed in them patients 
most frequently become worse towards night, from some 
slight accession of fever. Yet even the vacillating state 
of the health above noticed, always indicates an extreme 
susceptibility of the nervous system ; and as the influence 
of this system is very great upon the heart and arteries, it 
may at last lead to serious congestions or excitements of 
the viscera. When called to what are deemed nervous 
patients, practitioners should always be strictly on their 
guard, and examine, one by one, into the condition of the 
great vital regions, in order to be assured whether all be 
right there. 

Chronic inflammation of the kidneys is not uncommon, 
and it is generally denoted by an obscure uneasiness on one 
or both sides of the spine in the loins ; but this uneasines 
is mostly connected from the first with a furred tongue, and 
with an indistinct species of remittent fever, which after a 
time is generally marked in the evening ; and at this stage 
and period, there is often some degree of throbbing in the 
back, probably owing to the accumulation of blood in the 
larger renal arteries, from the resistance to its passage in 
the capillaries affected with the obstruction which we de- 
nominate inflammation. In some instances, I have known 
patients walk about for several weeks and even months, 
while they laboured under chronic inflammation of the kid- 
ney ; but it is one of those affections which sometimes ex- 
ists a long time before suppuration takes place, and it may 
therefore be removed occasionally under a Conjunction of 
very unfavourable signs. 

Chronic inflammation of the uterus is much more fre- 
quently connected with the lingering complaints of females, 
than most modern writers seem to be aware ; and if some 
practitioner who has time and talent, would thoroughly in- 
vestigate this subject, he would make a most important ad- 
dition to pathology and therapeutics. However absurd 
the speculations of the ancients might be, they were cer- 
tainly right in supposing, that the influence of the uterus 
was extremely great. Painful or irregular menstruation in 
young women is often connected with a degree of chronic 
inflammation of the uterus ; and, after days of suffering, I 



AND SULPHUREOUS WATERS. 43 

have known pieces of coagulable lymph expelled, apparent- 
ly from its inner surface, as they resembled a sort of deci- 
dua. About the time that the catamenia cease, great 
attention should be paid to females ; for chronic inflamma- 
tion of the uterus, which is almost always attended with 
pain in the back, is very apt to supervene, from the ple- 
thora which follows the suppression of a periodical dis- 
charge ; and to the same cause, stimulating the heart to 
an augmented action, may be traced many of those tumors 
in the mammae so common at this period of life. The 
best preventives of such affections, are a diet more abste- 
mious than before, and a moderate system of depletion, by 
those purgatives which keep the hepatic and intestinal se- 
cretions natural. Wherever a chronic discharge takes 
place from the vagina, whether bloody or leucorrheal, it 
generally may be regarded as an indication of chronic in- 
flammation of the uterus, when there are not enough con- 
stitutional symptoms present to account for it satisfactorily: 
but in all of such suspected cases, an examination per vagi- 
nam should be made, for a morbid sensibility of the uterus 
to the touch is the most common attendant, and the most 
certain test of its being the seat of chronic inflammation, of 
which excess in venery is among the most frequent causes. 
I have known some, and heard of other cases, in which a 
morbidly enlarged uterus was mistaken for a stricture of 
the rectum, from the pressure of the former against the lat- 
ter part impeding the descent of the feces, and giving them 
a flattened appearance. As such a mistake may entail a 
preat deal of unnecessary suffering on the patient, and even 
lead to mortal consequences, no practitioner should pro- 
nounce a disease of a female to be a stricture of the rectum, 
until he has ascertained the state of the uterus ; for should 
the examination be made solely by the rectum, he may be 
easily deceived if an enlarged uterus form a tumor which is 
apparently connected with the gut, and which often can 
only be discovered as a distinct affection, by elevating it 
from the vagina. In several instances, I have been con- 
sulted by females who complained much of the head, and 
whose digestive organs were manifestly disordered from the 
foulness of the tongue ; but on inquiry it was found, that 
uterine irritation, acting on the heart and thence on other 
organs, was the first exciting cause, which being removed. 



44 chronic diseases; 

all the other secondary symptoms abated. In all of the ap- 
parently bilious, dyspeptic, and nervous attacks offemaies f 
the state of the uterus should be ascertained, which through 
sympathy has considerable power over other parts of the 
body. 

Sympathy, no doubt, is an expression by which we some- 
times cover our ignorance, and prevent further inquiry. 
As commonly employed, it is a genera! term, under which 
different states are included, some of which are not strictly 
referrible to the influence of the nervous system ; and some- 
thing similar may be said in regard to the epithet nervous, as 
applied to diseases, for it is most vague and indefinite, and 
comprehends many discrepant affections. The progress 
of medicine has been retarded in every age, by the use of 
general terms, which rather refer to symptoms than explain 
diseases; and the nomenclature of chronic complaints is 
peculiarly open to amendment, since most of the names 
now employed only serve to conceal the real pathology of 
those complaints. The doctrine of what is called sympa- 
thy is intimately concerned with the phenomena of many 
chronic diseases ; for if one part be materially affected, it 
seldom fails to disorder some other part. The change of 
action which one organ is capable of effecting in another 
may be produced four ways : first, through a direct consent, 
between the nerves of different parts, which disturbs the 
capillary arteries of those parts ; secondly, through an 
anastomosis of the blood-vessels alone ; thirdly, through 
mechanical obstructions to (he circulation, which impels 
the blood in unusual directions ; and fourthly, through an 
irritation extending to the brain and heart, and finally ex- 
citing the whole arterial system, which in its turn disorders 
the functions of the weakest organs. But as it is my inten- 
tion to enter into the detail of this subject at a future 
period I shall not pursue it here, but throw out some gene- 
ral allusions bearing on the treatment of chronic diseases. 
In diseases of chronic congestion there is preternatural ful- 
ness of the internal veins ; indiseases of chronic inflammation 
there is preternatural fulness of some part of the capillary 
arteries ; and this fulness is so great as to disturb the func- 
tions of the organ in which it exists, and the whole economy 
by consequence is thrown into disorder. But the topical 
fulness, whether seated in the veins or in the arteries, may 



AND SULPHUREOUS WATERS. 45 

originate in general causes which give a shock to the heart, 
the main spring of the circulation ; and in such cases, the 
seat of the topical disease is determined by the predisposed 
states, or by the weakness of the respective organs attack- 
ed. If there be any predisposition to disease in an organ, 
that disease may be readily excited by any thing which 
greatly disturbs the action of the heart ; for though the 
predisposition remained latent when the whole circulation 
flowed with its natural calmness, yet when that circulation 
has once been agitated by some shock at its source, every 
organ must participate in the change, but especially the 
weakest. On the other hand, if any local disturbance 
should take place in the circulation of a part, the currents 
of blood sent by the natural action of the heart, if they 
should not remove, must necessarily increase that disturb- 
ance, upon the known principle of the motion of fluids : 
unless indeed those currents find other adjacent channels 
of conveyance, which are furnished by anastomoses, seem- 
ingly to provide for the prevention and reparation of inju- 
ries. In diseases of congestion the action of the heart is 
either oppressed or weakened. It may be oppressed by a 
preternatural load of venous blood about its right side and 
adjacent vessels, by which the return of the blood in the 
veins may be retarded and accumulated in various organs : 
it may be weakened by all those causes which diminish 
the tone and tenacity of the muscular fibre, so that from 
mere want of energy the blood might be too long and largely 
accumulated about the right side of the heart ; and there- 
fore it is, that some congestive diseases require depletion, 
and others a short stimulant plan, since in the first class 
the strength is merely suppressed, in the last it is enervated 
or exhausted. In diseases of excitement, on the contrary, 
the action of the heart is much increased, so that the forcing 
power of each ventricle sends the blood more frequently, 
if not more violently, through all the arterial channels of 
the body ; and it is easy to conceive how it may be ob- 
structed or accumulated, by some topical weakness, in the 
capillaries of those organs which had previously some 
unperceived tendency to what we call inflammation, which 
consists in a local accumulation of arterial blood, generally 
united to an increased action of the heart. But the in- 
creased action of the heart may be either primary or se- 



46 CHRONIC DISEASES, 

condary. It is primary when the heart is at once stimulated 
beyond its natural movement, so as thereby to influence 
some distant part, by transmitting a superabundance of 
blood there :— it is secondary when some local and remote 
disorder proves an irritant to the heart, rousing it into 
greater power than in health, by which it aggravates that 
disorder, from the force and frequency of the currents it 
transmits. Both in chronic and acute diseases, the func- 
tions of the right and left ventricle of the heart have by no 
means been sufficiently regarded ; but they are so exceed- 
ingly important that the heart perhaps may be considered 
as the origin or the support of all diseases connected with 
congestion or excitement ; for whether it be directly op- 
pressed or exhausted, whether it be directly stimulated or 
indirectly irritated, it must necessarily have an influence 
over all the organs, especially over those which had previ- 
ously been faulty. 

What has been called increased action in the arteries of 
a particular part, is generally a state of those vessels very 
different from increased action : for, so far as I have yet 
observed in inflammation, the action of one artery is not 
increased more than that of another, independent of the 
heart ; and what seems to be so, is obstruction or disten- 
sion, augmented by the natural or preternatural action of 
the heart. In conformity to the view above given, we 
lessen the action of the heart by evacuations, whenever 
we wish to remove a local disease affecting an important 
organ. When the secretion of any organ is increased, we 
say that the action of its arteries is increased, yet this does 
not legitimately follow ; for the action of an artery is one 
thing and its secretion another, and the increase of secretion 
may arise from an adjacent obstruction, or an augmented 
capacity of the vessels owing to an increase of the animal 
heat, by which more blood than usual is made to pass 
through the part. What we are accustomed to call increas- 
ed determinations of blood to particular parts, generally 
depend upon some adjacent obstruction, or upon some 
change in the temperature; and of this many instances 
might be adduced, but none perhaps is more striking than 
an acute rheumatism seated in one hand, where there is 
obviously an obstruction of blood in the capillaries of the 
joints affected, with an increased heat of the greater part 



AND SULPHUREOUS WATERS. 47 

of the fore-arm. On account of the obstruction in those 
capillaries, the blood cannot of course be freely returned 
by the veins, so that it accumulates in the radial artery, 
the volume of which is necessarily expanded by the blood 
and by the increased heat ; but though the volume of the 
pulse in that arm be always much greater than in the other 
which is unaffected, yet on counting the pulses in both arms 
I have invariably found them of the same number of beats 
at the same time, and therefore, mechanically speaking, no 
actual increase of action exists in the distended artery. 
Again, in the arterial disturbance called inflammation, we 
generally say that the action of the arteries is increased in 
the inflamed part ; and yet if we examine an internal in- 
flammation minutely, we shall be satisfied, that it is really a 
state of obstruction or distension, liable to be augmented 
by the currents of blood constantly transmitted by the 
heart. Our language respecting inflammation, and indeed 
respecting the whole action of the heart and the re-action 
of the arteries, is very defective in point of precision ; and 
at a future period, I shall endeavour to attach definite 
meanings to certain general expressions which are now 
commonly empoyed, and the vagueness of which still tends 
to retard our advancement. The animal heat is one of 
the great media of connexion between the nervous and the 
m vascular systems ; and I shall afterwards show, that an at- 
tention to this circumstance will contribute to explain many 
of the phenomena of disease, and many of the operations 
of remedies. 

If any local disease should finally be so great as to in- 
crease the action of the heart, other organs which had been 
previously predisposed may become disordered by that in- 
crease of action, in which the whole arterial circle partici- 
pates. Thus in chronic as well as in acute diseases, the 
heart is directly and indirectly concerned in their origin or 
progress ; and much of what is denominated sympathy may 
be traced to a direct disturbance of the heart from some 
constitutional shock, or to an indirect disturbance from 
some topical disorder. In both acute and chronic diseases, 
we have not sufficiently attended to the action of the heart. 
But, to return, it may be remarked, that diseases of 
chronic congestion are more simple than those of chronic 
inflammation, because the first are seated only in the larger 



48 CHRONIC DISEASES, 

veins of some of the viscera, and therefore are necessarily 
not numerous ; whereas the last, being immediately seated 
in the capillary arteries, which are ramified through every 
part, must, therefore, necessarily be numerous. In dis- 
eases of chronic congestion, the heart is either oppressed or 
actually weakened, and this is the cause of the diminished 
tone of the arteries, which transmit or conduct the power 
of the heart throughout their extent; but in diseases of 
chronic inflammation the action of the heart is augmented, 
and this is the cause of the increased fulness or of the in- 
creased frequency in the action of the arteries. As the 
symptoms in disease of chronic congestion and chronic in- 
flammation are varied by the functions of the organs where- 
in they are seated, so their effects are also varied by the 
difference in the natural structure of those respective or- 
gans.* This difference in the structure and functions of 
the organs affected will go far to explain the difference in 
the phsenomena attendant on chronic congestion and chron- 
ic inflammation ; but as, in the present state of our knowl- 
edge, the cure mainly turns upon the general analogies in the 
character and consequences of congestion and inflammation, 
the principles of practice are simpler than might at first ap- 
pear. It is, probably, in most chronic as in most acute 
diseases, that the seat of the most decided disturbance is de- 
termined by some latent weakness or fault which had ex- 
isted in the part previously to the open developement of the* 
complaint. 

Pale, spare persons are frequently the subjects of chro- 
nic congestion, though it is not uncommon in those who 
are corpulent, and who have naturally a lax muscular fibre. 
The pale, spare subjects here noticed, are often greatly ben- 
efited by one or two small general venesections, followed 
up by a mild course of purgatives; and if they should 
flag under these evacuations, small portions of diffusible 
stimulants should occasionally be allowed, in conjunction 
with a light nutricious diet, by way of supporting the action 
of the heart and arteries, and of tending to restore the 
natural balance of the circulation. But in the employ- 
ment both of diffusible stimulants and of a nutricious di- 
et, the greatest exactness is often required ; for if they 
be carried too far, they rouse the system into fever, and 
thus only remove fulness of the venous to the arterial 



*** 



AND SULPHUREOUS WATERS. 49 

system. When the veins are timely relieved of preter- 
natural congestion, the heart necessarily regains its power, 
as a spring when the superincumbent pressure is tak- 
en away; and the increase of action acquired is of it- 
self often sufficient to equalize the circulation, when aided 
by food which supports without exciting the body. When 
the pulse rises under the evacuant plan, it is a certain indi- 
cation that it is answering a good purpose ; but on the con- 
trary, when it becomes weaker, it is as sure an indication 
that this plan should not be pursued further, because it is 
then diminishing the power of the heart, and with it that of 
the arteries, and must therefore increase the venous con- 
gestion. In such delicate cases, the common modes of de- 
pletion are almost always injurious : yet a regular course of 
the Harrogate sulphureous water, so as to keep the bowels 
gently open, and to stimulate all the secretory organs, will 
be the best remedy ; though during its exhibition the pa- 
tient should occasionally use the tepid bath, and be placed 
in a fresh atmosphere, which is often highly beneficial. In 
many instances of chronic congestion, I have seen the most 
agreeable change induced by a removal from the town into 
the country ; and when we consider the invigorating power 
of pure air, we cannot be surprised if it should remove ve- 
nous congestion, by communicating a permanent tone to the 
heart and arteries. 

In corpulent subjects labouring under chronic conges 
tion, while the constitutional energy remains unexhausted, 
one or two moderate bleedings will mostly be serviceable ; 
and then the purgative plan may be pursued, until the 
prominent symptoms subside. But in these cases, as in 
those occurring in spare subjects, the warm bath is an ex- 
cellent auxiliary ; for it not only equalizes the tempera- 
ture, but brings a flow of blood to the surface, and thereby 
lessens the internal plethora of the veins. When corpu- 
lent subjects, however, are in a state of real debility, rather 
than of oppression from chronic congestion, the pulse al- 
ways sinks under venesection, the certain sign, as in the 
former case, of its impropriety; and then a regular perse- 
verance in the Harrogate sulphureous water will be as re- 
quisite as in spare subjects, upon whom depletion by the 
lancet produced similar effects. When chronic congestion 
is connected with oppression only, evacuants act as direct 

G 



50 CHRONIC DISEASES, 

stimulants in removing both the cause and the effect, and 
the system often soon regains its wonted vigour ; but when 
chronic congestion is connected with real debility, evacu- 
aiits tend to throw the heart into some degree of collapse, 
and the blood consequently still further leaves the arteries, 
and accumulates in the veins, and such measures are then 
either useless or pernicious. In all cases, therefore, a 
careful estimate of the patient's strength, and of the ten- 
dency of the treatment, ought to be made, that the last 
may be duly proportioned to the first; but as oppression 
and debility are very different states, and yet seemingly 
alike, we must not confound them in our inquiries, since 
depletion is always indicated in the one, however unsuita- 
ble it may be in the other. Sydenham has observed, that 
old people often bear bleeding well. This is particularly 
the case when they labour under chronic congestion of the 
brain or liver, which is so frequently the forerunner and at- 
tendant of their paralytic and apoplectic attacks ; and if 
practitioners wouid more frequently abstract small portions 
of blood from persons advanced in life, when there are 
clear indications of congestion in the brain and liver, health 
would often be pres_erved, and life prolonged, Many old 
persons have as large appetites as young, which they are 
apt to indulge with nutricious food ; and thereby an over- 
plus of blood is formed which the system does not require, 
as the body is not then to be built up as in the young. 
Sometimes indeed old persons are saved, for a time, from 
the danger of this plethora by a gradual deposition of fat 
which relieves the large vessels of fulness ; but when even 
old persons eat largely and continue thin, they are always 
in jeopardy from vascular distention, unless the bowels 
should be spontaneously lax, or unless the kidneys or the 
skin should secrete copiously. It is for the reason above 
explained, and the blood naturally then accumulating in 
the veins, that old people are frequently so much benefited 
by bleeding. Nevertheless, in aged people, the lancet 
should always be employed with becoming caution : for if 
it be rashly hazarded when they are really enervated, it 
will hurry them to the grave ; and in every instance where 
cause exists for hesitating about venesection, purgative 
medicines should be preferred, which are generally not 
only safe, but also efficacious evacuants. But in the chro- 



AND SULPHUREOUS WATERS. 54 

hie catarrhal affections of the chest, to which old persons 
are so subject, even purgatives should be mostly avoided, 
and those milder medicines termed laxatives should be sub- 
stituted, with the occasional use of the blue pill when there 
is any coexistent disorder of the liver ; and as for the lan- 
cet, it ought rarely to be thought of in such affections, es- 
pecially when the expectoration is free, or when the lips 
have a livid or bluish tinge from the obstructed respiration, 
for under both these circumstances blood-letting is com- 
monly very injurious. There are some patients, threaten- 
ed with apoplexy, whose powers are so broken up as to 
render general blood-letting extremely questionable ; but 
they commonly bear brisk and repeated purging with ad- 
vantage, in combination with local blood-letting and blis- 
ters. When by mistake the employment of the lancet has 
been carried much too far in chronic congestion, great gen- 
eral exhaustion occurs, with excessive irritation of the ner- 
vous system. Under such circumstances, opium is often 
eminently useful, not only in renewing the energy of the 
heart, but in calming the nervous irritation. 

In my treatise on typhus, the efficacy of calomel and opi- 
um, after bleeding and purging, was strongly insisted on, in 
acute and sudden congestion ; and an attempt was there 
made to show, that it tended to restore the balance be- 
tween the venous and arterial systems, by rousing the heart 
into play, and by removing unequal distributions of blood. 
Though this combination, like almost every other, has less 
power over chronic congestion, when preceded by evacua- 
tions, still it is sometimes \ery useful, especially if the liver 
be affected ; but under every form of this disease, mercury 
should only be given to correct the alvine evacuations, and 
to excite the heart and the secretory organs ; and when 
these purposes have been answered, it ought to be wholly 
withdrawn as speedily as possible. While short courses of 
mercury may be beneficial, long ones often break up the 
general strength, and leave the nervous system in an irri- 
table, and the vascular in a most vacillating condition; so 
that if the chronic congestion should have been removed, 
irregular determinations by the arteries are apt to take 
place, but especially in the organ that was formerly the 
seat of the venous fulness. As it is generally desirable in 
chronic congestion to maintain an action on the skin, sudo- 



52 CHRONIC DISEASES, 

rifics may frequently be conjoined to calomel with great ad- 
vantage ; and among these the best are opium, camphor, 
the compound powder of ipecacuanha, and antimony. 
When the brain, however, appears to be the chief organ of 
the congestion, the opium ought to be given with great care, 
until its effects have been decidedly ascertained ; for though 
in some cases I have known it highly serviceable, in others 
it seemed to aggravate the symptoms. The operation of 
opium in venous congestion of the brain requires much elu- 
cidation. As stimulants of the skin, blisters may sometimes 
be applied with benefit in diseases of chronic congestion \ 
but upon the whole, the warm shower-bath, strongly im- 
pregnated With salt, is one of the best cutaneous applica- 
tions, especially when followed by friction. Exercise on 
horseback is sometimes extremely beneficial in chronic 
congestion of the viscera, wherever seated ; and it will of- 
ten alone remove those anomalous symptoms of functional 
disorder of the heart, which put on the character of struc- 
tural derangement y though in all of such affections, the 
alvine evacuations should be kept in a healthy condition, 
by an occasional blue pill and laxative. 

If chronic congestioa should so suddenly increase as to 
put on an acute and dangerous character, prompt depletion 
will in .general be required : but even then moderation 
must be the golden rule, for no more blood should be 
drawn than to. free .the heart from oppression ; and the 
cure must afterwards be chiefly trusted to purgatives, and 
to the mildest mercurials, with the use of the warm bath, 
and blisters. In these sudden conversions of chronic into 
acute congestion, the surface is always cool, and the pulse 
oppressed, while the brain and liver are generally the 
parts much engorged with venous blood. If we inquire 
into the history of those attacks of apoplexy and palsy, 
which are now so common amongst emaciated or sedenta- 
r) people, we shall find, that they had generally been long 
preceded by symptoms of venous congestion about the 
brain and liver, and by a deficiency of arterial action on 
the skin. The sudden supervention of apoplexy or of pal- 
sy in such examples is most frequently owing to the influ- 
ence of the weather ; but in some cases it arises from those 
mental shocks which are met with in the world, and which, 
affecting the source of the circulation, powerfully influence 



AND SULPHUREOUS WATERS. 53 

its currents in the weakest organs. In acute congestion of 
the veins, however, it must be recollected, that depiction 
is only applicable at the first attack, when the vital powers 
are but oppressed, and not exhausted : for when an uni- 
versal collapse has once supervened, depletion will be al- 
most immediately fatal ; and the only thing which can then 
afford the remotest chance of success, is the toierabiy libe- 
ral administration of opium. In the collapse of cholera 
morbus, as was before observed, it is surprising what a fa- 
vourable change opium will sometimes produce under the 
most unfavourable appearances ; and in ail real exhaustions 
of the vital energy it is superior to any other drug with 
which I am acquainted. The operation of opium, like that 
of calomel, is modified by the conditions of ihe bodv under 
which it is exhibited ; hence in some diseases, small doses 
are prejudicial, while in others large ones are useful ; and 
hence, too, it may be extremely improper at one stage of 
a complaint, and highly expedient at another. A practical 
essay on the powers of opium is a desideratum m physic. 
It is too often prescribed in ordinary affections, and too 
seldom in some extraordinary ones. 

Many of the chronic inflammations of the viscera may 
be traced to the influence of our variable atmosphere on 
the surface, and from thence sympathetically on the vari- 
ous organs of the interior ; but many of them also are to 
be ascribed to strong diets and'drinks, and to high mental 
emotions, which stimulate the heart and arteries much be- 
yond their ordinary tone. The circulation of the heart, 
and that of all the vital machinery, which its action in- 
fluences, was intended to be performed at a moderate rate ; 
and if we incessantly and greatly increase the rapidity of 
the circulation, it is not to be deemed wonderful, that this 
vital machinery should be disordered or deranged by too 
much rapidity of motion. The cause of death in chronic 
diseases is in general mechanical, is in general dependent 
upon the lesion of some part of importance ; as ihe de- 
rangement of one part in a complicated piece of machinery 
will suffice to stop the movements of the whole. But the 
disordered actions which precede and produce derange- 
ment of structure in the human body are sometimes ix« 
ceedingly slow ; and this is especially the case in chronic 
inflammation, for it will often exist months or even years be- 



o4 CHRONIC DISEASES, 

fore it destroys the structure, or greatly impedes the func- 
tions of the organ affected, as we preceive in chronic in- 
flammation of the eyes. 

Wherever chronic inflammation maybe internally seated, 
the treatmentis to be regulated by the same or similar princi- 
ples ; but in the application of these principles we must never 
fail to make allowances for peculiarities of age, of previous 
and present habits, of constitutional discrepancies, and so 
forth. Most frequently, small or moderate venesections 
should be first tried from the larger veins ; and these 
* should be followed up by local bleeding, blistering, purga- 
tives, rest, and an antiphlogistic regimen : but where suc- 
cess does not attend these measures, small doses of calomel 
or of the blue pill may be prescribed until the system be 
slightly affected, and then, for the most part, they should 
be suspended, and the laxative plan continued. With a 
few exceptions, short or mild courses of mercurials have 
seemed to me far more beneficial than long or servere ones 
in chronic inflammation ; and this has been especially ob- 
servable when they have been used in combination with 
the Harrogate sulphureous water, a remedy whose purga- 
tive and alterative powers shall afterwards be explained. 
But in every instance of chronic inflammation the greatest 
attention should be paid to the diet ; for unless it be strictly 
untiphlogistic while the symptoms continue unsubdued, 
very little advantage is to be expected from any remedial 
plan. In many cases, which were deemed to depend upon 
weakness of the stomach, I have seen the most decided 
benefit from a very spare diet ; and that, too, where a con- 
trary one had been tried to maintain the strength, which it 
in fact diminished, by irritating and oppressing the stomach. 
What is called dyspepsia, is often a symptom attendant on 
diseases of the brain or of the liver ; and when that is the 
case, it can only be removed by removing the original 
diseases : but when dyspepsia is an idiopathic affection of 
the stomach, it is very frequently connected with a low de- 
gree of inflammation of that organ ; and then small bleed- 
ings, repeated blisters to the epigastrium, with purgatives, 
an occasional blue pill, and a spare diet, will constitute one 
of the best plans of cure. If dyspepsia be attended with 
frequent retchings or vomitings, fasting for some hours now 
and then has frequently an excellent effect 5 and indeed in 



AND SULPHUREOUS WATERS. 55 

most chronic cases where the stomach is irritable, nothing 
tends to restore its tone sooner than the rest which occa- 
sional fasting affords to its functions. After moderate 
evacuations, small doses of the liquor arsenicalis sometimes 
remove stomachic and cephalic affections of long standing ; 
but this remedy is more particularly useful in periodical 
pains of the head, \$hen its use is preceded by depletion. 
In all chronic complaints of the stomach the quality as well 
as the quantity of the food should be regulated; and when 
much acidity and flatulence is apparently generated after 
meals, vegetables ought to be sparingly used. 

In some anomalous affections of the bowels attended 
with violent and frequent returns of spasmodic pain, I have 
prescribed pretty full doses of the rectified oil of turpen- 
tine, and occasionally with complete success, even where 
every other measure had previously failed. One case of 
this description fell under my observation last year ; and as 
neither bleeding, purgatives, opiates, blisters, the tepid 
bath, nor any of the ordinary means, gave relief, about an 
ounce of the oil was administered, which soon put an end 
to the attack ; and whenever the spasms returned, it always 
produced a similar effect, though before its use the blood 
drawn most frequently exhibited some of the inflammatory 
crust. In every instance of its exhibition it acted as a 
powerful purgative, and dislodged large portions of morbid 
mucus which had probably been long adhering to the villous 
coat of the bowels. I have, too, seen considerable benefit 
from about forty or sixty drops of this medicine two or 
three times a day, in that peculiar complaint of the stom- 
ach where there is generally much uneasiness when it is 
empty, and where this uneasiness is mostly lessened by 
taking food. To administer a powerful stimulant in diseas- 
es connected with excitement is a practice opposed to our 
received theories of inflammation ; but it is nevertheless 
an interesting subject of inquiry to ascertain in what kinds 
and in what stages of inflammation certain stimulants may 
be sometimes efficaciously given ; for though in acute in- 
flammations experience precludes them, yet in chronic 
inflammations stimulant applications are sometimes useful. 
Now experience may perhaps afterwards show, that in cer- 
tain internal accumulations of venous or arterial blood, 
we may safely and even advantageously have recourse to 



56 CHRONIC DISEASES, 

Excitants for a time, though at present we have not yet 
arrived at any definite rule on the subject. When venous 
or arterial congestion has continued beyond a certain pe- 
riod, or has accumulated beyond a certain amount, the 
vessels seem to lose their tone, as we may perceive in 
chronic affections of the eyes ; and it is especially under 
such circumstances, t&at the use of stinjUilants either excites 
some chaage on the blood itself, or on the vessels, by 
which the morbid accumulation is removed. Even a com- 
bination of the evacuant and the stimulant treatment is 
sometimes beneficial in chronic as it is in acute diseases ; 
and this particularly when a local affection coexists wifti a 
real depression of the general powers. Yet stimulants at 
all times ought to be most cautiously resorted to even in 
chronic inflammation or congestion ; and these brief hints 
are only given here to awaken inquiry on a point of pathol- 
ogy and practice which has not been sufficiently investi- 
gated. 

In delicate constitutions it may frequently become an 
importantquestion, whether general or local bleeding should 
be employed ; and whenever there is a rational ground 
of doubt on the subject, the latter should have the prefer- 
ence. The beneficial effects of local blood-letting, by 
leeches in particular, have not perhaps been rightly appre- 
ciated by the profession ; and I was not myself aware of its 
great utility in this mode, until I strictly attended to its influ- 
ence over the action of the heart. Eight or ten leeches 
applied to any part of the surface of the body will rarely fail 
to reduce the force and the frequency of the pulse, in cases 
where the general excitement does not run high ; and it is 
somewhat surprising that I have frequently known the ap- 
plication of this number of leeches reduce the pulse more 
than a general venesection, though far more blood was 
taken away by the latter than by the former. It is easy 
to explain why we should weaken or actually stop the ac- 
tion of the heart by drawing a considerable quantity of 
blood from a large vessel ; but it is not so easy to explain 
why the motion of the heart should be generally weakened 
and sometimes stopped by the small portion of blood which 
a few leeches abstract. When we bleed with tolerable 
freedom from a large vessel, we at once cut off a certain 
current of blood which was destined to be sent to assist 



AND SULPHUREOUS WATERS. 57 

in stimulating the right chamber of the heart into action ; 
and this current being thus cut off, the heart falls into a tem- 
porary collapse, for want of the full and necessary supply 
of its wonted stimulus — the blood. *On the occurrence of 
faintness, the momentum previously given to the blood in 
the arteries, by the contraction of the left ventricle, suffi- 
ces to complete its circulation there : while the right ven- 
tricle, in returning from its state of contraction, draws in 
the venous blood, until it is completely filled; and the 
wonted actions of the heart again succeed from this accu- 
mulation of blood about its right side. In some individuals, 
small or moderate losses of blood are sufficient to throw 
the heart into a collapse, by depriving it of a portion of its 
natural stimulus ; but in others a large quantity of blood 
must be drawn to produce such an effect, so different is the 
natural condition of the heart in different subjects. When 
death occurs from hemorrhages, it depends upon the col- 
lapse of the right side of the heart. In fact, when the right 
side of the heart has not been supplied with its due pro- 
portion of blood, on account of hemorrhage, fainting or 
syncope is the natural mode in which its action is again 
renewed : for during fainting or syncope the blood leaves 
the arteries, and, returning by the veins, accumulates about 
the right side of the heart, where it once more restores the 
movements of perfect life. But in certain cases of he- 
morrhage the loss of blood is so great, that enough is not 
returned by the veins to renew the contraction of the right 
ventricle : and hence the transfusion of blood into the 
veins, or the inflation of the lungs with oxygenated air, are 
expedients which claim an especial attention in such for- 
midable examples. But the prosecution of this point 
would lead me into a long digression here ; and the original 
subject shall therefore be resumed, relative to the influence 
of local blood-letting by leeches. 

It has, I trust, been in some degree explained, why draw- 
ing blood from a large current returning to the heart, may 
weaken or even stop the motion of that organ ; but the ab- 
straction of a few ounces of blood by leeches, rarely fails to 
diminish the action of the heart, and sometimes to stop it 
entirely ; and as this effect, in general, cannot wholly de- 
pend upon the quantity of blood lost, upon what does it 
depend ? Of the fact I am certain, from an accurate ac- 

H 



,38 CHRONIC DISEASES, 

count kept of the operation of local bleeding, by leeches, on 
patients in various instances; yet I must confess myself 
incompetent to explain it, though no doubt it is connected 
with those sympathies which exist between the nerves of 
one part and another. This fact, however, is applicable 
to many cases which are daily occurring in practice, since 
it may enable us to accomplish by small abstractions of 
blood, what we might have deemed only producible by full 
general venesection. It is the common opinion, that the 
efficacy of local blood-letting is chiefly attributable to re- 
vulsion, by which the fluids of one part are elicited to 
another ; and though this doubtless has often some influ- 
ence, yet accurate observation will convince any practi- 
tioner, that the principal power of local blood-letting is to 
be ascribed to its influence over the heart, like that 
of general phlebotomy. In the treatment of the acute 
diseases of children, and of the chronic diseases of adults, 
the method of local blood-letting may be exceedingly 
useful on many occasions when carried so far as to 
affect the pulse ; for in both cases it is often highly desira- 
ble to save the strength, by abstracting no more blood than 
is just sufficient to weaken the action of the heart, without 
exhausting the whole system. The cupping glasses, which 
Mr. John Welsh invented, are excellent auxiliaries after 
the application of leeches, since when they are applied 
over the punctures, they continue to abstract blood with 
very little uneasiness ; whereas the common method of 
cupping is frequently attended with considerable pain, the 
stimulus of which may tend to counteract the good effects 
of the loss of blood, by reacting on the heart where that 
organ is highly excitable. But local, like general blood- 
letting, will seldom be of any service in internal diseases, 
except where it is carried so far as to weaken the pulse ; 
and as this is a practical axiom, it ought never to be disre- 
garded, in the treatment of serious complaints, whether 
chronic or acute. In this department of the work, I have 
said but little about the chronic affections of the chest, to 
which the aged in particular are so exceedingly liable ; yet 
most of these will be found to be more or less connected 
with chronic inflammation of the bronchia, concerning 
which some remarks have been made in the section on con- 
sumption. As for affections of the heart, my experience 
is not sufficiently precise to enable me at this time to de~ 



AND SULPHUREOUS WATERS. M 

veiope their charaeter or treatment ; but I would merely 
suggest, in common with Dr. Hamilton, that disorders of 
this organ should never be considered as hopeless until 
a course of medicine has been tried to correct disturb- 
ances of the digestive functions, to which affections of 
the heart are so often secondarily related. 

Most practitioners, who have pursued the commonly 
adopted principles of practice, must be ready to confess, 
that the result of their experience has mostly been unsatis- 
factory in chronic diseases in general. It was the want of 
success which led me to abandon the tonic plan in by far 
the greater number of cases, and the treatment recom- 
mended was gradually substituted, and at last its superior 
efficacy amply confirmed by experience of its effects. Fu- 
ture observation will bear me out in asserting, that the 
weakness of which patients so constantly complain in chro- 
nic diseases, for the most part is only the consequence of 
some venous or arterial fulness oppressing an important or- 
gan ; and it may be regarded as an axiom, applicable to 
most cases, that to prescribe solely for a sense of weakness 
in these affections is a mere delusion, as the states upon 
which it depends must be removed, before the least ap- 
proach can be made towards recovery. In the preceding 
pages it has been attempted to show, how those states are 
to be removed or lessened when seated in vital parts ; yet 
it must be remembered, that they are only remediable when 
unconnected with organic derangement, which is their 
ultimate and mortal product. Nevertheless it is not rea- 
sonable to expect, that any plan of treatment will succeed 
in all cases of chronic disease, even when they are not 
combined with organic derangement ; and I have accord- 
ingly found the methods recommended at times ineffectual, 
even when they were tried under circumstances which sim- 
ply indicated disorder of function, without any concomitant 
sign of disorganization. In examples of chronic disease 
which resist the application of all ordinary means, it is 
common for physicians to send the patient to some water- 
ing place, most frequently with the hope of amusing his 
mind, and of allowing the sanative powers of nature to 
operate with the least molestation. So for back as the 
year 1807, it has been customary with me to send patients 
of the above description to Harrogate, recommending them 



60 CHRONIC DISEASES, 

to drink the sulphureous water there ; and at first 1 merely 
did so under the impression, that as the water was a mild 
purgative it might possibly do some good, aided by the 
change of scene, and by fresh air. But so early as the au- 
tumn of the year abovementioned, my attention was forci- 
bly directed to the power of this physical agent, by its 
apparently curing an obstinate affection of the liver, which 
had previously resisted all the usual measures ; and since 
that time I have not only endeavoured to investigate the 
operation of the Harrogate, but also of similar sulphureous 
waters, so that the following remarks may be considered 
as the result of pretty extensive observation. 

The first thing which struck me in regard to the opera- 
tion of the Harrogate sulphureous water was, that the bow- 
els might be opened by it day after day, week after week, 
without debility being produced ; nay, on the contary, most 
of the patients gained both strength and flesh notwithstand- 
ing they had daily and copious evacuations. This circum- 
stance alone seemed to give the sulphureous water a most 
decided advantage over the purgatives in common use ; for 
it must be admitted, that they cannot be long continued in 
chronic diseases, without diminishing the strength. For 
some time, therefore, I solely attributed the efficacy of the 
sulphureous water to its purgative property, together with 
the peculiarity that its long continued exhibition caused no 
debility ; and as for a considerable period, the compl aints in 
which I prescribed were chiefly stomachic and hepatic, I 
was the more confirmed in this opinion as to its operation. 
But cases of chronic disease fell under my observation at 
various times, in which the sulphureous water was most 
decidedly beneficial, and that too where the bowels had 
been but scantily moved ; and as the effect in these cases 
could by no means be purely attributed to its action on the 
intestines, I was led to inquire whether it might not have 
some other agency which had escaped my observation. In 
attending more closely to the changes which this water in- 
duced, I found that it acted most powerfully on all the se- 
cretory organs of the body, but more especially on the 
liver, on the kidneys, on the villous coat of the intestines, 
and on the skin. Here a new operation was presented to my 
inquiry. In reflecting on all the facts which had come before 
me, I ascertained that this water had removed chronic afTec- 



AND SULPHUREOUS WATERS. 61 

tions of various interna! and external parts; and hence at 
length the inference followed, that it was really beneficial as 
a very powerful alterative, and that it had a direct influence 
over chronic inflammation, wherever it be seated, whether 
in the viscera, or upon the surface of the body. In still 
further pursuing the consideration of the subject, I was fully 
satisfied, that 1 had arrived at a general principle in the 
operation of the sulphureous water; for, some time after- 
wards, on trial of that at Dinsdale, near Darlington, J found 
that its effects were also very powerful in chronic inflam- 
mations, though it be but slightly laxative. It at once, there- 
fore occurred to me, that the chief efficacy of the sulphur- 
eous waters of Harrogate and of Dinsdale depended upon 
the sulphureted hydrogen gas, which they both contained ; 
and indeed the principal difference between these two wa- 
tersis that the first contains less of the sulphureted hydrogen 
gas, but more of the saline materials than the last ; so that 
by adding very small doses of purgative salts to the one, it 
may be made to operate like the other, in many cases. 

Mercury has been universally esteemed the most power- 
ful alterative which has ever been used ; and most prac- 
titioners are now convinced that its efficacy, in acute as 
well as in chronic affcections, depends upon its action on 
the secretory organs. Now in the sulphureted hydrogen 
gas, we have another agent which acts as powerfully as 
murcury on the secretory organs ; but with this difference, 
that while the long continued use of the latter, in chronic 
diseases, generally breaks up the strength, that of the for- 
mer generally renovates the whole system. The sulphur- 
eted hydrogen gas, then, has a decided superiority over 
mercury in chronic diseases in general ; and this is not a 
speculative opinion, for I have proved its correctness in 
numerous instances by the test of experience. Chronic 
diseases, as their very name and nature imply, come on and 
advance by slow degrees, and we mostly find, that they can 
only be overcome by measures, the operation of which is 
continued for a considerable time. Hence it is, that in 
chronic diseases we do not find bleeding and purging act 
with the same force and rapidity as in acute diseases. It 
we relied upon these as our chief remedial powers in 
both diseases, we should be compelled to repeat them more 
fYequently in the former; and even then we should ven 



62 CHRONIC DISEASED 

often break up' the general strength, and our success in the 
main would be much less certain than in acute diseases, 
which generally yield to a repetition of such active expe- 
dients. In chronic diseases, therefore, it is quite a desi- 
deratum to possess an agent which shall operate daily and 
favourably, that the desired change may be at last induced, 
without injuring the general system by the treatment ; and 
from an extensive observation of its effects, I may confident- 
ly affirm, that this agent is to be found in the sulphureted 
hydrogen gas, combined with laxative agents, in the min- 
eral waters of this country. 

It has been observed that the sulphureted hydrogen gas 
resembles mercury in its operation, inasmuch as it acts on 
all the secretory organs, but that in one respect it differs 
from mercury in its operation, inasmuch as its long continu- 
ed use does not exhaust the energy of the system. There 
are, however, other points of resemblance between these 
two remedies, which it may be proper to mention, that the 
mode of administering the sulphureted hydrogen gas may 
be fully understood. When the system resists the specific 
action of mercury, it is a certain test that an inflammatory 
diathesis prevails to a considerable extent, and this is the 
cause of the resistance ; for lessen the inflammatory dia- 
thesis by proper evacuations, and then the specific action 
of the mercury will readily be induced. Now something 
similar obtains in regard to the sulphureted hydrogen gas, 
since when the system is impervious to its influence, it is 
on account of an inflammatory diathesis in a more than 
ordinary degree ; yet only let that inflammatory diathesis 
be diminished by the lancet or by purgatives, and then the 
sulphureted hydrogen gas will produce all its beneficial 
effects. This point it is of great consequence to remem- 
ber in practice : for as the powers of mercury have often 
been frustrated through an omission of previous evacua- 
tions, so the powers of the sulphureted hydrogen gas may 
be frustrated by the same circumstance. Yet in the ma- 
jority of examples, the phlogistic state does not run so high 
in diseases of chronic inflammation as to resist the efficacy 
of the daily administration of the gas ; but when those dis- 
easeas are seated in the head, or in the abdomen, the cure 
will mostly be much accelerated by procuring a purgative 
as well as a specific operation from the sulphureous waters. 



AND SULPHUREOUS WATERS'. 65 

Hence it has appeared to me in cephalic and abdominal 
affections, that the Harrogate are generally more effica- 
cious than the Dinsdale waters, when simply prescribed as 
nature has presented them ; while on the other hand, the 
Dinsdale water has appeared to me more efficacious than 
the Harrogate, in chronic inflammations of the chest, in 
chronic inflammations of the joints, and in some very ob- 
stinate affections of the skin. But the operation of the 
Dinsdale water may be made to resemble that of the Har- 
rogate, by dissolving in it minute portions of purgative 
salts ; and as it contains more of the sulphureted hydrogen 
gas, so it will sometimes overcome distempers which had 
resisted the influence of the Harrogate water. During a 
series of years I have traced the operation of the sulphur- 
eted hydrogen gas from one organ of the body to another, 
from the skin, joints, and eyes, to the viscera of the head, 
chest, and belly: and the sum of my observations would 
authorize me to declare, that it is one of the most power- 
fully antiphlogistic agents which can be found ; for wherever 
the chronic inflammation be seated, it will, I believe, more 
frequently remove it, than any other mean, provided the 
bowels be kept regular during its administration. 

In several chronic affections of the head and abdomen, 
when aided by small bleedings and moderate purging, it 
has effected a cure where mercury had completely failed ; 
and although the efficacy of mercury is so notorious in 
chronic affections of the liver, yet upon the whole I am 
disposed to think, that is inferior to that of the sulphureted 
hydrogen gas. In many hepatic diseases, however, it will 
be best to combine the operation of these two remedies at 
the same time ; and this plan will often be found of vast 
advantage, but especially if the Harrogate water be employ- 
ed so as daily to act as a purgative. Small doses of calo- 
mel, or of the blue pill, may be given for a short period ev- 
ery night at bed-time ; and a large tumbler-glassful of the 
Harrogate water may be administered on the following 
morning before breakfast, and repeated every twenty min- 
utes, until it operate by the bowels. But in such cases, the 
mercury should not often be given longer than a week or 
ten days : some mild purgative pill may then be substitut- 
ed at bed-time, and the sulphureous water continued every 
morning, until the symptoms entirely disappear. In con- 



64 CHRONIC DISEASES, 

junction with this treatment, it will occasionally be requi- 
site to apply a blister now and then to the right hypochon- 
drium ; but in most instances this 'auxiliary will not be 
required, though in some obstinate cases it will be found 
very efficacious, when rapidly repeated. In what are 
termed stomach complaints, a regular perseverance in the 
Harrogate water will frequently do more good than all the 
medicines in the pharmacopoeia ; but in these, as in hepatic 
affections, it will sometimes be requisite to assist its purga- 
tive operation by an occasional blue pill, or by one of the 
compound rhubarb or aloetic pills at bed-time; and on 
certain occasions, a blister may likewise be beneficially ap- 
plied over the epigastrium, and even repeated so long as 
the symptoms remain unsubdued. Chronic rheumatism 
and gout, and almost all cutaneous affections, will yield 
more rapidly to the continued internal exhibition of the 
sulphureted hydrogen gas, than to any of the means now 
commonly employed ; but in these, and also in most chro- 
nic complaints of the viscera, the recovery will be consid- 
erably expedited by the frequent use of tepid baths which 
contain the sulphureted hydrogen gas. In many parts of 
this volume I have strongly insisted on the importance of 
attending to the functions of the skin both in health and 
disease ; and I am fully persuaded, that much of the effica- 
cy of the sulphureted hydrogen gas is to be attributed to 
its action on the skin, through the innumerable pores of 
which it operates with remarkable power. At the same 
time it is to be recollected, that it is not upon one, but up- 
on all the secretory organs, that it exerts a special influ- 
ence ; but certainly to the skin, as it is so capacious, a large 
portion of that influence is directed, and next in degree it 
is generally spent upon the kidneys, both of which circum- 
cumstances make it so beneficial in cutaneous diseases, and 
in those of the urinary organs. 

A remedy, then, so highly effiacacious in chronic inflam- 
mations in general, might seem at first sight well fitted for 
phthisis and similar insidious affections ; and though my 
experience is very incomplete with respect to its powers 
in confirmed consumption, yet it has seemed to me exceed- 
ingly useful in several instances where phthisis was dis- 
tinctly threatened. But this has been more especially 
observable, when the pectoral symptoms were complicated 



AND SULPHUREOUS WATERS. 65 

with hepatic disorder, as frequently occurs ; and indeed in 
the commencement of most fevers of the hectic type, the 
sulphureous waters have afforded more relief than any 
thing else. In a few solitary cases, which bore the char- 
acters of genuine and confirmed phthisis, and in which pus 
was expectorated, a marked change for the better took 
place from the drinking of the Dinsdale waters; and I re- 
cently saw two remarkable examples, which appeared to 
be cured by this mineral spring, though in both the disease 
was far advanced when it was first tried. All the meas- 
ures hitherto recommended by authors having proved most 
fallacious, it becomes a question of the greatest importance 
to society, to ascertain precisely the powers of the sulphur- 
ated hydrogen gas, both in the incipient and confirmed 
phthisis ; and as I have formerly shown, that the closest sym- 
pathy exists between the lungs, skin, and kidneys, and as 
I have also ascertained, that this physical agent acts most 
powerfully on both these organs, the consideration of it has 
still stronger claims to our regard. Besides, numerous tri- 
als have fully convinced me, that in all chronic inflamma- 
tions of an ordinary nature, this gas has one common and 
specific operation 5 and as it cannot be denied, that phthisis 
is an inflammatory affection, we might surely expect it to 
have some influence. It may however be urged, and justly 
too, that the inflammation attendant on the tubercular 
consumption is not of an ordinary, but of a peculiar kind : 
yet in answer to this objection I can state, that the internal 
and external use of the sulphureous waters are far more 
efficacious in scrofula than the common measures ; for af- 
ter all the ordinary treatment had failed, I have seen scro- 
fulous affections cured or lessened by drinking these waters, 
and using them as a tepid bath. Now if phthisis really be 
scrofula of the lungs, which is my firm opinion, why may 
it not also prove serviceable in that affection, as well as in 
others of a similar character, though of a different seat ? 
Dr. Rollo was the first, so far as 1 know, who suggested 
the internar use of the sulphureted hydrogen gas in phthisis, 
but as he did so, in common with some successors, upon 
merely speculative grounds, the remedy has been disre- 
garded ; and if the few facts and hints, which are here of- 
fered, should call the attention of the medical public more 
particularly to the subject, general inferences for or against 



m CHRONIC DISEASES, 

the efficacy of this agent in phthisis may at last be estab- 
lished, by more extensive trials than I have yet been ena- 
bled to make. But it ought to be mentioned, that in the 
advanced stages, the Harrogate water is prejudicial in 
phthisis, by acting on the bowels from the purgative salt 
which it contains ; and though the Dinsdale possess no in- 
gredient of this sort, yet my experience has not enabled me 
to determine whether it ever produces any thing like a 
colliquative diarrhoea. At the same time as no such effect 
was observable in the cases reported above, I am inclined 
to think, that it has a decided superiority over the Harro- 
gate water in the advanced stages; indeed this remark is 
also applicable to examples of apparently incipient or 
threatened phthisis, except where the liver is affected, and 
then the Harrogate is perhaps the best. 

It is not in phthisis alone, that the sulphureted hydrogen 
gas has been neglected by practitioners in general ; for in 
the whole class of chronic diseases, to which it is so pe- 
culiarly suited, the ordinary routine of palliatives is pursu- 
ed in private practice, while this remedy is unnoticed or 
unknown. Nay, I have heard it said, that some profes- 
sional men of deserved eminence assert, that the sulphure- 
ous waters of this country have no decided efficacy in chro- 
nic diseases ; but I dare nevertheless pledge my word, that, 
if they be only fairly and fully tried, they will be found 
amongst the most powerful agents which ever have been 
brought to the relief of human maladies. Most patients 
are sent to drink the sulphureous water at Harrogate for 
cutaneous affections, and as these are in general connected 
with disorders of the digestive organs, they are often readi- 
ly cured ; since the sulphureted hydrogen gas, assisted by 
the minute portion of salts in solution, operate at the same 
time upon the morbid states of the digestive organs, and 
upon those of the surface. But from a legitimate generali- 
zation of the facts which have fallen under rny observation. 
1 am justified in the opinion, that this remedy has a specific 
action suitable to all diseases where a certain degree of the 
inflammatory diathesis prevails ; and since diseases of chro- 
nic congestion in the veins generally require a similar treat- 
ment to diseases of chrpnic inflammation in the arteries, 
the applicability of the sulphureted hydrogen gas to those 
shall next be concisely noticed. 



AND SULPHUREOUS WATERS. 67 

For a considerable time the pathology of no diseases em- 
barrassed me more than those which 1 have denominated 
congestive: for when of an acute kind, patients were at 
once overpowered, not only without excitement, but with 
positive proofs of an oppressed state of the heart and arte- 
ries ; and when they assumed a chronic character, patients 
became pale, and apparently feeble, with a similar but less 
diminution in the tone of the pulse. In both cases, there- 
fore, the symptoms were very different from those which 
attend inflammation, and it was not until I obtained morbid 
dissections, that I became fully convinced of their real na- 
ture. Inflammation is a disease seated in the arteries, con- 
gestion is a disease seated in the veins ; and as inflamma- 
tion may be either acute or chronic, so in like manner may 
be congestion. Great discoveries in science, whatever 
light they may throw at the time they are made, sometimes 
tend afterwards to retard the progress of knowledge ; for 
men, considering that all has been revealed which can be 
on the subject, often sit down contented without prosecut- 
ing the inquiry any further. Thus it has happened, that 
the great discovery of our illustrious countryman, Harvey, 
has had an ultimate tendency in preventing us from ex- 
ploring the many obscurities which still hang over some 
parts of the circulation of the blood in health and in dis- 
ease ; and thus it has happened, too, since his time, that 
almost every medical writer, who contemplates diseases 
chiefly through the vascular system, has placed them in the 
arteries, and disregarded the veins. But all those acute 
and overwhelming affections, which destroy before the ap- 
pearance of re-action, and most of those chronic and op- 
pressive affections, under which patients crawl about pallid 
and sunk, are seated in the veins of the viscera; and until 
we cease to view the majority of them as diseases of real 
debility, we shall only continue to pace the unprofitable 
and beaten round of blind, of dangerous empiricism. In a 
former work I endeavoured to show the superiority of the 
depletory and the alterative to the purely stimulant plan ; 
and in the foregoing pages have intimated the applicability 
of a similar but modified plan, to the greater number of 
those chronic cases which are strictly congestive. But as 
the strength is only suddenly overpowered by attacks of 
acute congestion, and as it is slowly sapped by chronic con- 



68 CHRONIC DISEASES, 

gestion, so in almost all examples, the depletion must be 
more cautiously made in the last than in the first ; for the 
quantum of depletion which would relieve the system from 
the load of acute congestion, would frequently exhaust the 
remains of the latent energy, which the chronic congestion 
had concealed under the mask of apparent weakness. On 
the contrary, very small or very moderate bleedings will 
often answer an excellent purpose in chronic congestion, 
when followed up by purgatives, and a few doses of calo- 
mel and opium ; but where this treatment does not suc- 
ceed, and where there still appear evidences of venous ful- 
ness about some of the vital regions, then the continued 
use of the sulphureous waters, with the occasional employ- 
ment of the warm sulphureous bath, will be preferable to 
any other known expedients. 

The sulphureous waters, it has been affirmed, and could 
be proved by numerous cases, operate specifically on the 
secretory organs ; so that during their administration a sys- 
tem of evacuation is going on from almost all the capillary 
exhalants. As this evacuation may be continued for days 
and weeks, and yet induce no debility, it seems peculiarly 
calculated for cases of chronic congestion ; and accordingly 
I have frequently seen it most serviceable, where other 
measures had failed to hee the system from a superfluity 
of blood in particular parts. In all chronic diseases of 
consequence, the functions of the skin undergo great and 
manifest changes, bi:t this especially happens in those of a 
congestive kind ; for in them the surface is generally 
blanched, and lax, while the temperature of it is either be- 
low the natural standard, or exceedingly variable. But 
the sulphureous waters, used internally and externally, 
rarely fail to improve the condition of the skin, in chronic 
congestion ; and though the state of that organ be in many 
respects widely different in chronic inflammation, yet even 
then they also frequently restore its natural functions. 
Those shrunk and sallow persons who are deemed nervous, 
bilious, or hypochondriacal, often labour under some chro- 
nic congestion of the brain or liver : and in these cases, 
the greatest benefit will sometimes result from a steady 
perseverance in the use of the sulphureous waters. But 
whenever the head or liver is affected, alvine evacuations 
should in general be daily procured ; so that if the Dinsdale 



AND SULPHUREOUS WATERS. 69 

waters be used, a little salt must be added to them, and it 
will only be necessary when the Harrogate waters are taken, 
to give a mild laxative pill the night previous to their exhi- 
bition. 

In persons who are deemed to be of the nervous temper- 
ament, there is a peculiar irritability of the heart, and its 
action of course is liable to be disordered by slight as well 
as by severe causes ; but these persons generally suffer 
most from mental emotions, which always make the heart 
palpitate, and on some occasions it will seem to flutter 
almost like a bird in the breast. During these inordinate 
motions of the heart, there are often what we term deter- 
minations of blood to the brain, and sometimes to other 
organs ; but a state of collapse often succeeds such deter- 
minations, and this collapse again may be followed by im- 
perfect excitements of the heart and arteries. It is thus, 
as it were, vibrating between one extreme and another, 
that such persons often pass their lives with but few inter- 
missions of ease, when they are placed where the mind is 
agitated; and most practitioners must well know from ex- 
perience, that little or no relief is obtained from the usual 
remedies, tonics and antispasmodics. Nor indeed can 
much good be effected by any measures, unless the mind 
can be secured against violent shocks ; but at the same 
time, more benefit will be obtained from the sulphureous 
waters, which act as purgatives, than most other measures. 
As for tonics and antispasmodics, they are generally worse 
than useless ; but especially the last, which, being strong 
diffusible stimuli, often do serious mischief in naturally 
irritable habits. The nervous temperament may be hered- 
itary, or it may be engendered by circumstances in the 
progress of life ; but wherever it exists, the heart will be 
found peculiarly susceptible, and accordingly all excitants, 
whether mental, medicinal, or otherwise, should be studi- 
ously avoided. In many families, but especially where the 
nervous temperament prevails, some one organ is weaker 
than the rest, a peculiar defect liable to be transmitted 
from generation to generation ; and in such cases, the 
weakest organ is sure to suffer from the morbid motions of 
the heart, from whatsoever causes they may proceed. 
People of the nervous temperament are o^en almost as 
much influenced by vicissitudes of the weather, as by men- 



70 CHRONIC DISEASES, 

tal affections ; and. in such instances the skin is generally 
first disordered, and the heart next. Between the skin 
and the heart there is a most intimate sympathy, so that 
the changes induced in the one, often powerfully affect the 
other; but independent of this nervous sympathy, the ab- 
straction of heat from the surface often powerfully influen- 
ces the heart, for in that case the blood leaving the superfi- 
cial retires into the deeper seated veins, and is thus returned 
superabundantly to the right auricle and ventricle. 

It has already been mentioned, that the sulphureous 
waters will sometimes fail in chronic diseases of disordered 
action simply : and this probably happens in cases where 
the blood vessels have been so long distended, as to have 
lost in some degree the power of returning to their ordinary 
state ; but nevertheless, in the main run, these waters will 
answer an admirable purpose in chronic diseases, when 
deranged structure is not present. At the same sime it 
ought always to be recollected, that they*may easily be 
brought into disrepute from short or imperfect trials of them; 
and therefore they should, for the most part, be continued 
daily, in sufficient quantity, until the disease completely 
gives way, or until their inefficiency has been fairly proved 
by an unremitted perseverance. In some chronic cases of 
ophthalmia, of rheumatism, and of cutaneous affections, I 
have known them to effect a cure in two or three weeks : 
while in other cases, apparently similar in all respects, 
twice, thrice, or even four times that period has elapsed 
before the cure has been accomplished ; and what is here 
affirmed of these external affections is still more strongly 
applicable to internal diseases, which are seldom speedily 
overcome by these waters, how completely soever they 
may yield at last. In illustration of this point as to internal 
diseases, it may be mentioned, that I have seen both chro- 
nic inflammations of the liver, and chronic inflammations of 
the rectum, where no benefit was produced for three or 
four weeks ; and yet a continuance of the waters for six or 
eight weeks longer, has eifaced every vestige of the morbid 
indications for which they were prescribed. The long use 
of ordinary medicines almost always tends to injure the 
general powers of the system ; but this is not the case with 
those waters mhich contain the sulphureted hydrogen gas 
largely, for tney have an invigorating influence, though 



AND SULPHUREOUS WATERS. 71 

taken almost daily for weeks together. Yet whenever the 
sulphureous waters are prescribed, their operation should 
be narrowly watched ; and they should always be omitted 
for a time when they produce head-ache, a white tongue, 
or some degree of febrile irritation. Some of these effects 
may follow their first exhibition, and especially when pre- 
scribed for subjects of a phlogistic diathesis ; and similar 
symptoms also are apt to arise occasionally from their long 
continued use. Before they be re-administered in such 
cases, the employment of purgatives is commonly neces- 
sary, the operation of which generally removes the febrile 
irritation, so that they afterwards mostly act without occa- 
sioning any similar inconvenience. But in all affections 
combined with vascular fulness the bowels should be daily 
moved during their exhibition ; otherwise they may be 
liable to heat and irritate in a way almost similar to mercu- 
ry. Nor need we fear, with the exception of complaints 
of the chest, to purge patients freely every day with the 
Harrogate water ; for under this system of depletion, they 
generally gain flesh and strength, particularly in gastric, 
hepatic, and intestinal affections. The tepid bath of sul- 
phureous water, along with its internal use, is mostly very 
serviceable; but the temperature of the bath should be 
duly regulated, otherwise it may cause considerable ex- 
haustion. The tepid bath of sulphureous water is most 
indicated in complaints of the skin, chest and belly ; but it 
ought always to be had recourse to with caution, when the 
head is affected, as it may increase the flow of blood to- 
wards the brain. 

Some elaborate and excellent works have been written 
on cutaneous diseases, butmost practitioners will be ready to 
confess, that the modes of treatment recommended are of- 
ten ineffectual : the internal and external use, however, of 
the Harrogate, or of the Dinsdale sulphureous spring, will 
rarely fail to cure such affections ; and indeed I dare assert 
in general terms, without the dread of refutation, that these 
seemingly simple compositions of 'nature are of far more 
efficacy in diseases of the skin, than all the various and 
complicated formulae of art. But in the treatment of all 
the scaly affections of the skin, it will be found a most im- 
portant point to remove the scales by friction or some simi- 
lar means, that the waters may be applied to the skin itself. 



72 CHRONIC DISEASES, 

Indeed I am convinced, that many practitioners fail in 
complaints of the skin, merely from applying their remedies 
upon the surface of the scales : whereas if they were to 
remove the scales daily, the use of the sulphur ointment, 
or of a tepid bath of sulphureous water, would frequently 
succeed ; provided the digestive organs be properly regu- 
lated, for they are often concerned in the production and 
continuance of cutaneous disieases. 

The treatises which have been hitherto published on the 
sulphureous waters above mentioned have not met with 
that attention which their merits deserved ; but as I was led 
to investigate and to generalize the operation of these wa- 
ters, without reference to what other writers had previously 
done, so perhaps I may be allowed to hope, that my un- 
biassed research respecting them may induce the medical 
faculty to give them an impartial trial. For my own part, 
however, I would not be content that the sulphureous 
springs of this country should be more frequently recom- 
mended than they have hitherto been by practitioners, but 
that attempts should be made to prepare artificial waters of 
the same constituents ; and though these might perhaps be 
of less efficacy than the natural springs, still they might 
prove highly serviceable in the class of chronic diseases, 
which so often baffle us in private practice. That artificial 
waters which contain the sulphureted hydrogen gas, may 
be put correctly and extensively to the test, 1 should advise 
them to be used internally as a medicine, and externally as 
a bath, in some of our large hospitals; where wards could 
be set apart for those chronic cases to which the sulphur- 
eted hydrogen gas appears to be so peculiarly applicable,, 
from its powers of inducing a complete change in the sys- 
tem, through the secretory organs. 

The analysis both of the Harrogate and Dinsdale waters 
shows, that the sulphureted hydrogen gas is the most pre- 
dominant and active principle in each, and therefore it is 
natural that we should ascribe the efficacy of these waters 
to this principle. But both waters contain some carbonic 
acid gas, and some azotic gas, and that of Harrogate espe- 
cially, small portions of various neutral salts, while that of 
Dinsdale holds some sulphur suspended; so that the first 
is in reality a purgative, and the last a very mild laxative 
at best, when taken to the amount of a pint or more in 



AND SULPHUREOUS WATERS. 73 

the day. It is on account of the small portion of the neutral 
salts dissolved in the Harrogate sulphureous water, that it 
chiefly operates on the bowels : and even in the prescrip- 
tion of purgatives for chronic diseases, we would do well to 
imitate nature in this particular ; for repeated observation 
has convinced me, that we give far too large doses of purga- 
tivesaltsiri chronicdiseases,the effect of whichgenerally is to 
irritate the system first and to exhaust it afterwards. Eight 
or ten grains of the sulphate of magnesia, with forty or fifty 
of the common salt, will generally purge mildly and eifect- 
ually, when dissolved in about a pint of water ; and these 
doses may be frequently repeated without producing ex- 
haustion ; whereas if we often prescribe an ounce or an 
ounce and a half of the sulphate of magnesia, or of a simi- 
lar salt in chronic diseases, we should in the end usually 
find, that considerable debility had been induced from their 
repeated exhibition and operation. Every grain of salt which 
we prescribe is probably taken up by the absorbents, and min- 
gled with the mass of blood, before it acts, through the ex- 
halants, as a purgative to the intestines ; and if this be the 
fact, we may readily comprehend, why so much irritation 
should often follow large doses of salts in chronic affections. 
In acute diseases, every moment is precious, and therefore 
the agents which we employ should be given in powerful 
doses, that they may operate with the least possible loss 
of time ; but in chronic diseases, where there is no occasion 
to produce an immediate effect in this way, it is surely 
much better to trust to milder measures, the operation of 
which cannot do harm, if they should do no good. Indeed 
it appears to me that the whole plan of prescription in 
chronic diseases stands in need of amendment ; for the 
large doses of purgatives and other medicines, which we 
so generally give, frequently tend rather to increase than to 
relieve the symptoms, from the irritation and exhaustion 
which they produce. 

In the preparation of artificial waters, impregnated 
strongly with sulphureted hydrogen, it will become a ques- 
tion whether the other ingredients should be added, which 
are found in the natural springs ; but a little experience 
will soon enable us to decide this question, since if the sul- 
phureted hydrogen alone should be found ineffectual, it 
would follow that the rest are also required for the reduc- 

K 



74 CHRONIC DISEASES, 

tion of chronic inflammation or congestion. From the 
trials which I have made of the sulphureous waters in 
chronic inflammation and congestion, it has forcibly struck 
me, that they might be also serviceable in acute inflamma- 
tion and congestion, conjointly with other measures of 
known utility ; and it would not at all susprise me to find the 
sulphureted hydrogen gas hereafter ranked amongst some 
of our most efficacious agents, as well in acute as in chro- 
nic diseases. Measured by cubic inches, the Harrogate 
water contains about a twelfth part of sulphureted hydro- 
gen gas, but considerbly more than that proportion is in 
the Dinsdale ; and in the common water impregnated with 
this principle, we might easily so* regulate the quantities, 
as to make its operation vary according to the circumstances 
of particular cases. Yet perhaps we are too much accus- 
tomed to suppose, that we can successfully imitate, by 
artificial means, the effects of mineral waters, because we 
detect such and such ingredients in them by analysis. It is 
highly probable, however, that these ingredients, or their 
elements, exist in certain combinations which we cannot 
imitate, and which are changed by our very modes of analy- 
sis; so that though artificial may approach in the operation 
to natural mineral waters, yet the latter will always perhaps 
be found to possess powers which human ingenuity can 
never communicate to the former. Some part of the effi- 
cacy of mineral waters may perhaps depend upon the sim- 
ple principle of dilution ; and to this principle is to be 
attributed most of the utility of such remedies as the de- 
coction of sarsaparilla, which many so highly value. The 
effects of the common waters which we daily drink, is a 
subject deserving of more consideration than it has receiv- 
ed. It would probably be found, on inquiry, that many 
complaints are connected with the substances which they 
contain. Why, for example, does the stone so much more 
frequently occur in some counties than in others ? The 
state of the fluids may be affected, and thence of the solids, 
by our ordinary drinks ; and it is not unlikely, that in this 
way ossification and similar affections of the arteries are 
sometimes produced. 

The sulphureous waters, like many other things, have 
probably been neglected, because they are openly presented 
to our observation, and appear exceedingly simple at first 



AND SULPHUREOUS WATERS. 7.3 

sight ; but it seems to me, that the beneficent Author of out 
being has intended them for the advantage of mankind, 
how much soever they have hitherto been disregarded. 
The whole world around us is a spectacle of beauty or 
or sublimity, the impressions of which upon our senses arc 
fitted to promote our happiness in health ; and is it at all 
unreasonable to suppose, that things have also been pre- 
pared to restore us from many of the sufferings of sickness ? 
It is my firm opinion, that physic might be greatly advanced 
by a minute inquiry into the medicinal properties of those 
substances which are presented and prepared by nature ; 
and as the subject is one of mighty interest to mankind, so 
it is to be expected, that it will not be overlooked in the 
prosecution of the chemical combinations of the present 
times. The consideration of the sulphureous waters alone 
suggests, that if one gas may be taken into the stomach, 
absorbed, and carried through the circulation with striking- 
benefit, others also may probably be found which might be 
useful in various diseases ; and as the inhalation of gases 
has hitherto only ended in disappointment, a different re- 
sult may perhaps be anticipated from their employment in 
a different mode. But it is not this circumstance alone 
which strikes us in reflecting upon these waters, for the 
small portions of salts dissolved have active and excellent 
powers ; and therefore we are naturally led to suppose, 
that we should attend to the minute divisibility of many of 
the preparations in common use. The mineral springs 
which contain iron have only a very small portion of that 
metal suspended in them, and yet they are far more effica- 
cious than the ferruginous preparations which we prescribe; 
and here we are again led to conclude, that our ordinary 
mode of administering this metal should be abandoned, and 
one substituted similar to that which nature has offered to 
our observation. There is a divisibility in the preparations 
of nature, which is unpractised in the usual combinations 
of art ; and it would probably be well for mankind, if this 
divisibility were much more frequently imitated in medical 
prescriptions. 

My principal reason for having thrown together some 
general remarks on chronic diseases, was to put the medi- 
cal public in possession of the results of my experience 
concerning the sulphureous waters : but as. in tho existing 



76 CHRONIC DISEASES, 

state of things, these waters connot be recurred to by u 
numerous class of patients, I have mentioned the means 
most useful where such auxiliaries are not procurable. If, 
in objection to the general doctrine laid down concerning 
the nature of slow diseases, I should be asked, were they 
all uniformly marked by chronic inflammation or chronic 
congestion. I would certainly answer, that the most essen- 
tial parts of those diseases generally consist in these two 
states. Yet it must be acknowledged, in the first place, 
that a disorder in the functions of some of the important 
organs does exist for a considerable time, without unequivo- 
cal symptoms either of chronic inflammation or chronic 
congestion. From what cause, then do these disorders of 
function arise ? The progress of such affections generally 
shows, that they must at all events be closely connected 
with one or other of these morbid states, however latent or 
obscure ; because if the disorder of function be not re- 
moved either by nature or by art, chronic inflammation or 
chronic congestion in time becomes manifest, and a founda- 
tion may therefore be laid for derangement of structure. 
Thus we have an almost evident proof, that even in the 
minutest of the capillaries,chronic inflammation or chronic 
congestion may long obscurely exist, and only come slowly 
into open view at last. What we usually call predisposi- 
tion to a disease in an organ probably consists in a degree 
of preternatural accumulation of blood in the capillary ves- 
sels of that organ ; so that when any constitutional shock 
comes to disturb the action of the heart materially, the 
mischief falls upon the part thus pre-disposed, because there 
the capillary circulation would be most impeded. Since 
the time of John Hunter, it has become the fashion in this 
country to explain all morbid phenomena simply by stating 
that they depend upon some change of action; but this 
word change of action is a general term without any precise 
signification, and is only calculated to conceal our ignor- 
ance from ourselves. If the term change of action be 
applied to the arteries and veins, its application must be ex- 
ceedingly limited, because the action of these vessels them- 
selves is limited. The arteries seem to possess the vis 
reciliendi, or what might be mechanically termed re-action, 
the power of recoiling from the stroke of the heart, and 
they likewise seem to possess the property of accommoda- 
ting themselves to their contents. This last property. 



AND SULPHUREOUS WATERS, 



77 



which prehaps might be termed their irritability, the 
veins also possess in common with the arteries ; and it is not 
improbable, that this property may be so imparied in certain 
states of the system as to allow the blood preternaturally to 
accumulate in them, and thus pave the way to many acute 
as well as chronic diseases. But mere change of action in 
a vessel, as above explained, will not account for all the 
facts which we daily observe in morbid deviations ; and 
we must take into account the state of the fluids which circu- 
late in, or are secreted from, these vessels, together with 
the conditions of the nervous system, before we can at all 
satisfactorily solve what we now call mere change of action. 

But there is a state of the circulation, local as well as 
general, which has been confounded with inflammation 
both in acute and chronic diseases, and yet this state differs 
from inflammation. When it occurs locally, it is marked 
by a change in the secretion of the part, as, for example, 
we may daily see in the investing membrane of the tongue 
in chronic and in acute complaints ; and nevertheless, 
though we are fully satisfied that the part is morbidly af- 
fected, yet w t e cannot pronounce that affection to be inflam- 
mation. When this state occurs generally, it is always ac- 
companied with an increase in the action of the heart, and 
an increase in the animal heat, though the blood seems so 
equably distributed throughout the system, that no one vis- 
cus can be said to be more decidedly disordered than the 
rest ; but even in this case there is a change produced in 
the secretions which alike attends the local as well as the 
general state of the circulation, though in the local there 
generally appears to be some topical accumulation of blood, 
which does not, however, amount to the measure of inflam- 
mation. Still, both in acute and chronic diseases, this lo- 
cal and this general state of the circulation may pass into 
inflammation, and in fact frequently does so, where it is not 
spontaneously or artificially removed; and hence, in both 
acute and chronic diseases, inflammation may arise at some 
period of their progress, though in the first instance they 
were not complicated with inflammation. At present we 
have no word in our language to mark this state as essen- 
tially distinct from inflammation ; but as it occurs in many 
diseases, perhaps for want of a better, it might be discrimi- 
nated by the term simple excitement* 

Where disorder of function alone, as frequently occurs 



78 CHRONIC DISEASES, 

in the stomach and liver, marks the deviations from health, 
the sulphureous waters are exceedingly serviceable ; for 
by reaching and searching the most minute ramifications of 
the capillaries, they remove the morbid condition of these 
vessels, which are so apt, on mechanical laws, to be the 
first seats of disease, from their immense number and te- 
nuity. And where chronic congestion of the veins exists 
in combination with a real exhaustion of the heart, as we 
sometimes see in the inhabitants of large towns, the use of 
these waters, but particularly of the Dinsdale, is sometimes 
attended with the most striking benefit ; as they contribute 
to communicate an energy to the whole muscular fibre, 
and an exhilaration to the spirits, which are never witness- 
ed from the administration of ordinary means, under simi- 
lar circumstances. In those long-continued diseases, where 
manifest proofs of disorganization exist, it is far too much 
the practice to prescribe long and severe courses of mer- 
cury, which in general, so far from doing any good, only 
hurry patients to the grave. In fact, all that we ought usu- 
ally to attempt in such cases, is to lessen suffering, and to 
protract life ; and for both of these intentions the sulphure- 
ous waters, with pure air, and occasional anodynes, will 
frequently answer the best purpose. It must be familiar 
to every person of experience how rapidly sometimes the 
general powers give way under a continued system of or- 
dinary evacuation, even when chronic inflammation or 
chronic congestion is uncombined with any actual disor- 
ganization ; and it is of great importance, that this truth 
should be constantly before the mind of the practitioner, 
lest he push his measures so far as to prejudice the patient 
while he leaves his disease unsubdued. But the system of 
evacuation produced by mineral waters, when properly 
used, has none of these debilitating effects ; and therefore 
it is a desideratum in physic to ascertain their powers more 
precisely than has hitherto been done^ especially in slow 
diseases, which baffle the ordinary means. Chronic in- 
flammation of the uterus may be ranked amongst the most 
formidable of those diseases, under some of its modifica- 
tions ; and it would be particularly desirable to ascertain 
whether the external and internal use of sulphureous wa- 
ters would be serviceable, since many of the means usually 
employed hardly deserve the name of palliatives. It has 
been intimated to me, by one whose judgment I highly res- 



AND SULPHUREOUS WATERS. 79 

pect, that I have shown an attachment to particular reme- 
dies, hut especially to sulphureous waters. In the history 
of medicine, nothing is more striking than the undue par- 
tiality which writers show towards certain agents which 
they have been accustomed to use ; and it would be pre- 
sumption in me to suppose, for a moment, that 1 am so far 
exempt from bias as to have escaped a common imperfec- 
tion of human nature. In my future observations, how- 
ever, I shall endeavour to take a cautious review of the 
influences of those measures which have been recommend- 
ed ; and if a more extended experience should convince 
me of any mistake, that mistake shall be acknowledged and 
corrected without hesitation. Yet so strong is my confi- 
dence of the efficacy of sulphureous waters in slow disea- 
ses attended with functional disorder, that I could wish 
some of the intelligent practitioners who reside at the 
springs would collect and publish a series of cases in which 
those waters were employed. The simple recital of such 
facts would, I believe, teach a most instructive lesson to 
the medical world ; for it would show that whatever yet may 
have been effected by mercurials and purgatives in chronic 
complaints, may often be more pleasantly and completely 
effected by these simpler means. 

It will at once strike the accurate observer, that there are 
some diseases, which though they may be connected with 
chronic inflammation or chronic congestion, yet have some- 
thing so peculiar in them, as to deserve the epithet spe- 
cific ; and among such remarkable affections may be men- 
tioned, diabetes and cancer, the characters of which are so 
distinct, and the nature so obscure. In one, if not in both 
of these complaints, the fluids undergo changes, which have 
not yet been sufficiently regarded : and however we have 
neglected the humoral pathology in modern times, its in- 
vestigation is really calculated to throw great light on some 
parts of medical science. Whether the sulphureous waters 
could be successfully applied to diabetes, cancer, and other 
diseases, which have hitherto been so unmanageable, must 
be left for others to determine ; but certainly from their 
known efficacy in numerous diseases which resist ordinary 
measures, they deserve a fair trial in these peculiar affec- 
tions ; and the more especially so, since if they should not 
prove beneficial, they would at least be perfectly harmless. 

Pathology and physiology are so intimately related, that 



80 CHRONIC DISEASES, &c. 

the doctrines of the latter frequently extend their influence 
to the former; and it has appeared to me, that the progress 
of physic has often been retarded by physiological arrange- 
ments founded upon artificial distinctions. Perhaps the 
most natural order in which the functions of the body could 
be classed, would be into the vital, the mechanical, and the 
chemical. The vital functions are chiefly referrible to the 
brain, nerves, and spinal cord; the mechanical chiefly to 
the heart, vessels, and muscular powers ; and the chemical 
chiefly to the fluids circulating in or secreted from the ves- 
sels. These functions have each their peculiar laws, and 
yet they are connected with each other. Perhaps in cer- 
tain diseases, the vital functions are chiefly in fault, in 
others the mechanical, and in some the chemical. Yet so 
intimate is the relation between these functions, that in 
many acute and chronic complaints, they all seem to par- 
ticipate. Thus, for example, contagion primarily affects 
the vital functions through the nervous system, then the 
action of the heart and vessels becomes disturbed, and 
lastly the secretions undergo manifest alterations. Again, 
an irritation of some part shall be slowly produced, and 
exist some time without apparently exerting any influence 
on the general habit ; but at length the irritation acts upon 
the heart, thence upon the arterial system, and the secre- 
tions in like manner are finally changed. But the order 
here mentioned, as to the functions affected, does not al- 
ways obtain, for the first deviation from health may be in 
the mechanical or the chemical functions, so that the vital 
may only be secondarily implicated. Any system of physic 
which, as such, shall make approaches towards stability, 
must comprehend each of these functions, with their res- 
pective influences, in a state of disease, upon the various 
tissues of the body ; and it has been the error of most med- 
ical writers that some bias towards a favourite doctrine has 
prevented them from taking a comprehensive survey of 
morbid phenomena. There are yet some relations to be 
discovered between the nervous and vascular systems, 
which will materially change the aspect of pathology ; and 
chemistry has also yet to reveal some secrets in the doc- 
trine of the fluids by which we shall be led to important 
and useful changes in theory and practice. 



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